Date: December 9th, 2024

Time: 1pmET | 12pm CT | 11am MT | 10am PT

Duration: 90 Minutes

Description:

Restraint and seclusion practices are critical areas of focus for both CMS and the Joint Commission, with hospitals often cited for non-compliance. This program will delve into these challenging standards.

CMS has developed extensive interpretive guidelines—spanning fifty pages—regarding restraint and seclusion for hospitals. All facilities that accept Medicare patients must adhere to these regulations, regardless of accreditation status with organizations like the Joint Commission, HFAP, CIHQ, or DNV Healthcare.

It’s essential for any physician or provider who orders restraint to be well-versed in the hospital’s policy. Both CMS and the Joint Commission mandate annual education for hospital staff on restraint and seclusion guidelines. Furthermore, CMS stipulates that training must occur before any staff member or provider can apply or remove restraints and that it should be continuous, rather than limited to initial orientation. There are ten pages dedicated to training requirements.

Lastly, this program will provide a brief overview of The Joint Commission’s standards on restraint and seclusion, which closely align with CMS Conditions of Participation.

Learning Objective

• Recall that CMS requires all physicians and others who order restraints to be educated on the hospital policy.
• Describe that CMS has restraint education requirements for staff.
• Discuss that CMS has specific things that need to be documented in the medical record for the one-hour face-to-face evaluation of patients who are violent and or self-destructive.
• Define the CMS restraint requirement of what a hospital must document in the internal log if a patient dies within 24 hours with two soft wrist restraints on.

Agenda

• Restraints in the news.
• Introduction to CoP Manual.
• Deficiencies – restraints and seclusion.
• Complaint manual and process.
• Conditions of Participation.
• Seclusion – what it is and is not.
• Medical restraints.
• Behavioral health restraints.
• Definition of restraint and seclusion.
• Reasons to restrain.
• Leadership responsibilities.
• Falls and use of restraints.
• Drugs used as a restraint.
• What restraints do not include?
• Side rails, forensic restraints, freedom splints, immobilizers.
• Patient assessment.
• Need order ASAP.
• Order from LP and notification to attending physician.
• Documentation requirements.
• Least restrictive requirements.
• RNs and One-hour face-to-face assessment.
• Training for RNs doing the one-hour face-to-face assessment.
• Training requirements.
• Ending at the earliest time.
• Revisions to the plan of care.
• Time-limited orders.
• Renewing orders.
• Provider training.
• Staff education.
• First aid training is required.
• Monitoring of patient in R/S.
• Death reporting requirements.
• Joint Commission standards.

Who Will Benefit:

• All nurses with direct patient care.
• Compliance officer.
• Chief nursing officer.
• Chief of medical staff.
• COO.
• Nurse Educator.
• ED nurses.
• ED physicians.
• Medical staff coordinator.
• Risk manager.
• Patient safety officer.
• Chief Risk Officer.
• PI director.
• Joint Commission coordinator.
• Nurse managers.
• Quality director.
• Chief medical officer.
• Security guards.
• Accreditation and regulation staff and others responsible for compliance with hospital
• regulations.
• Anyone involved in the restraint or seclusion of patients.
• Any staff that could remove/apply restraints as part of care

About Our Speaker

Laura A Dixon

Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director, of Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included the creation of presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.