Restraining patients? CMS now requires more training
Rule tightens use of restraint and isolation
Nurses or physicians who place patients in restraints or in isolation now must meet stricter training and documentation requirements thanks to a strengthened federal patient's rights rule effective as of Feb. 6.
Chiefly, the new patient's rights rule issued by the Centers for Medicare & Medicaid Services (CMS), as it applies to physical restraints and seclusion, requires that health care workers who employ these measures undergo new, more rigorous training aimed at ensuring that the treatment is appropriate and that patients' rights are protected.
The new rule is a requirement, or condition of participation, that all participating Medicare and Medicaid hospitals must meet. The rule applies to short-term, psychiatric, rehabilitation, long-term care, pediatric, and substance abuse hospitals.
The new patient's rights regulation address a patient's right to notification of his or her rights in regard to care; privacy and safety; confidentiality of their records; and freedom from the inappropriate use of all restraints and seclusion in all hospital settings.
Increased emphasis on evaluation
Prior to the new rule, CMS required that a patient have an in-person, face-to-face evaluation by a physician or other licensed independent practitioner (LIP) within an hour of being restrained or secluded.
Under the new rule, the list of LIPs extends to registered nurses (RNs) and physician assistants (PAs); however, when an RN or PA performs the one-hour evaluation, a physician or other LIP treating the patient must be consulted as soon as possible.
In developing the final rule, CMS took into account feedback from providers, patient advocates, and others in the health care and civic communities, dovetailing those concerns with the primary focus of patients' physical and emotional health and safety.
Under the new regulations, hospitals must provide patients or their family members with a formal notice of their rights at the time of admission. These rights include freedom from restraints and seclusion in any form when used as a means of coercion, discipline, convenience for the staff, or retaliation. Restraint is intended to protect the patient from harm to himself or others.
CMS' final rule on patient rights adds training requirements for nurses, physician assistants, and other staff members that exceed the previous CMS rule or standards set out by the Joint Commission on Accreditation of Healthcare Organizations. The new regulation requires staff be able to show they are competent in restraining, monitoring, evaluating, and caring for patients in restraints before they are permitted to play any role in the restraint of patients.
Hospitals are mandated to ensure their staff receive training and demonstrate knowledge in:
- techniques to identify staff and patient behaviors, events, and environmental factors that could trigger the need for restraint;
- nonphysical intervention skills;
- determining the form of restraint or isolation that is the most effective and least restrictive;
- the safe application and use of all types of restraints their hospitals use;
- determining when restraints are no longer necessary in a patient;
- monitoring the well-being of the patient, including vital signs, injury, respiration, circulation, and any other requirements identified in hospital policy;
- first aid and CPR, including periodic recertification.
The CMS rule won't change much for many hospitals, which have taken patient restraint seriously as a patient safety issue, as well as a medical-legal issue, for some time. Mike Cruz, MD, FACEP, director of quality assurance for the emergency department at OSF Saint Francis Medical Center in Peoria, IL, says the one-hour evaluation window doesn't pose a problem in most emergency rooms, because the physicians are right there.
"In our department, by the time we decide to restrain a patient, it's an issue of the patient's safety and the staff's safety," he says; at that point a physician, as well as a nurse and physician assistant, probably has already been involved.
Saint Francis, like many hospitals, will not be impacted much by the new CMS rule, Cruz says, because it is already meeting or exceeding the requirements.
"I don't know that [CMS] is asking us to do anything more than what we already are," he says. "All nursing staff have to have that training, and that gets updated and audited two or three times a year. I specifically audit it because of the high-risk nature [of restraining patients]."
Tighter reporting standards for patient deaths
The new CMS final rule on patient restraints imposes stricter standards for reporting the death of a patient when the death is associated with use of restraint or seclusion.
Previously, CMS required hospitals to report all deaths that occurred during restraint or if restraint might reasonably be assumed to have played a role in the death.
Under the new rule, however, CMS must be informed about every death that occurs while a patient is restrained, every death that occurs in patients within 24 hours of being removed from restraints, and every death that occurs in patients within one week after they were restrained if it can be reasonably assumed that the restraints played a direct or indirect role in the death.
Deaths in any of these three categories must be reported no later than the next business day after hospital staff learn of the death, and the report to CMS must be documented.
"Through this regulation, CMS will hold all hospitals accountable for the appropriate use of restraint and seclusion," according to Leslie V. Norwalk, acting administrator of CMS.
The new CMS final rule on patients' rights can be found in its entirety at www.cms.hhs.gov.
Nurses or physicians who place patients in restraints or in isolation now must meet stricter training and documentation requirements thanks to a strengthened federal patient's rights rule effective as of Feb. 6.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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