Greeley survey solutions: Time to start working on restraint

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Editor’s note: Each month, an expert from The Greeley Company will discuss a hot-button topic or challenging issue facing hospitals in the areas of accreditation, survey preparation, and more. This month’s article is by consultant Gayle Bielanski, RN, BS, CPHQ. Have a question for our experts? E-mail Matt Phillion at

Before tracers, restraint was one of the most frequently cited RFIs (formerly known as “Type 1” recommendation). We have a hunch restraint citations may be coming back to the top 10 list.

First, The Joint Commission recently made significant changes to the restraint standards to more closely align with CMS’ Conditions of Participation. We expect extensive surveyor training with a corresponding renewal of focus on this subject.

Second, CMS (or, more correctly, the state agency representing CMS in your neighborhood) tends to focus on restraint during its validation surveys, typically asking for a sample of recent restraint/seclusion records.

Although this is not The Joint Commission’s current survey process, as surveyors only review restraint records if they happen to choose a restrained patient during a tracer, with The Joint Commission’s deemed status up for renewal, there may well be a more focused approach on future surveys. We recommend measuring compliance with your policy. Start by focusing on the following direct impact elements of performance:

PC.03.05.01’s five elements are direct impact and focus on the indications for each episode of restraint, including discontinuation of restraint at the earliest possible time.

Tip: Drive documentation of indications into very simple forms or templates that do not rely on check boxes.

PC.03.05.03, EP 1 requires the use of safe techniques to restrain patients according to hospital policies and procedures.

Tip: Do not make a separate policy or procedure related to techniques. Rely instead on a well-designed education program.

This program, which can be available to all staff members in real time, ensures alignment of practice across the organization and avoids the need to develop duplicative procedures.

PC.03.05.05, EP 5 applies to restraint used only for the management of violent or self-destructive behavior. It requires an in-person evaluation by the physician at least every 24 hours.

Tip: Behavioral restraint rarely lasts more than 24 hours. However, if this happens at your hospital, make sure the provider is visiting the patient often. Do not wait until the 23rd hour to call for a physician visit. Consider following the former Joint Commission rule, which is no longer in effect for deemed-status hospitals, and have the physician perform a face-to-face evaluation every eight hours (i.e., at every other renewal).

PC.03.05.05, EP 6 requires renewal of medical restraint, according to hospital policy. One instance of a missing order could generate a direct impact RFI.

Tip: Consider the use of protocol orders with specific criteria for discontinuation. There is no longer a requirement that orders be renewed each calendar day.

PC.03.05.07, EP 1 requires that trained staff members monitor patients in restraint or seclusion.

Tip: Ensure that competency in restraint use is measured and documented at the time of orientation. Don’t forget about security guards or other nonlicensed personnel you rely on to observe patients in locations such as the emergency department.

PC.03.05.09, EP 2 requires that physicians and other licensed independent practitioners who order restraint have a working knowledge of the restraint policy.

Tip: Consider including a brief half-page flyer signed by physicians during the credentialing and privileging process. This will supplement, not replace, physician education efforts. Additionally, hard-wire the policy into preprinted order forms or templates that force documentation related to appropriateness, assessment, and indications for discontinuation.

PC.03.05.11, EP 1 requires a one-hour face-to-face evaluation of violent or self-destructive patients by a responsible physician or an appropriately trained RN or physician assistant (PA).

Tip: Ensure that all RNs who staff the emergency department or the behavioral healthcare unit have documented training in the monitoring of violent or self-destructive patients.

PC.03.05.11, EP 2 requires a nurse or PA who performs the one-hour face-to-face evaluation of violent or self-destructive patients to consult with the responsible physician as soon as possible after initiation of restraint.

Tip: When possible, have the physician perform the one-hour reassessment. Hard-wire documentation of consultation with the physician when this assessment is performed by the nurse or a PA. Do not rely on a separate timed note.

PC.03.05.11, EP 3 specifies the content of the one-hour evaluation of violent patients.

Tip: Hard code this documentation into forms or computer templates.

PC.03.05.13, EP 1 requires the continuous observation of patients who are simultaneously restrained and secluded.

Tip: If video equipment is used for monitoring, make sure there is also an audio signal from within the room. Remember, this applies only to patients who are restrained and secluded at the same time.

Note: All direct impact requirements for this subject are Category A, meaning a single deviation noted will yield an RFI. There are many other requirements, but you should first consider the Category A direct impact requirements.