MDS Alert

This risk management snapshot is only part of the picture.

Say your restraint quality measure/indicator looks pretty good or is on the decline. Before you breathe a sign of relief, read on.

The QM/QI can give you a "general indication as to how your practice compares to other facilities in the state and nation" in terms of physical restraint use, says Steven Littlehale, MS, APRN, BC, chief clinical officer for LTCQ Inc. in Lexington, MA.

But beware these four key reasons why counting on the restraint QM/QI alone as a risk management tool can lead you down a rosy path to inappropriate restraint use and F tags.

1. The QI/QM does not include admission assessments, Littlehale points out. That's a "good thing" from a survey standpoint in that you're "not held accountable for residents admitted with a restraint," he says. But the QM/QI won't flag residents who need attention to reduce or eliminate their restraints -- or address the underlying issue that led them to be restrained in the first place. For example, the facility's QM/QI report can identify 0 percent restraints, says Littlehale. But when you walk through the unit, you may see several restraints on newly admitted residents, he adds.

2. The QI/QM only counts daily restraints, notes Liz Frost, RN, director of nursing at Hearthstone nursing facility in Seattle. Thus, "a trunk restraint used six out of seven days [during the lookback] won't trigger the QM/QI," Littlehale cautions. That's "obviously misleading for your restraint reduction and risk management plan," he emphasizes.

3. The indicator doesn't include bedrails that act as a restraint. The QM/QI is triggered by residents who have a daily trunk or limb restraint or those in a chair that prevents them from rising. The omission of bedrails as restraints is "a bitter pill to swallow," says Littlehale, in that "a true restraint reduction program includes [bedrails] as a focus," he says.

"Bedrails provide caregivers and family members and residents a misleading sense of security. There are better, more respectful and safer ways to prevent residents from falling out of bed," Littlehale says.

4. The restraint QM/QI won't give you credit for restraint reduction efforts in all cases. The resident "may be using a less restrictive form of restraint -- or for much less time during the day even though it's still daily," observes Nancy Augustine, MSN, RN, also a consultant with LTCQ Inc.

Run Your Own Numbers

Regularly "collect, tabulate and review" the numbers of various types of restraints used in the facility "and their appropriateness," advises Stephen Trosty, JD, a risk management expert in East Lansing, MI. The facility should also have a "culture of safety" where staff feel comfortable reporting inappropriate use of restraints, adds Trosty.