Letter to State Survey Agencies: Medicare & Medicaid Clarification of Standards for Use of Physical Restraints on Patients in Long Term Care Facilities
Letter to State Survey Agencies: Medicare & Medicaid Clarification of Standards for Use of Physical Restraints on Patients in Long Term Care Facilities
Letter to State survey agencies: Medicare and Medicaid Clarification of Standards for use of physical restraints on patients in LTC facilities
No. 07-22, June 22, 2007 (submitted to CCH Online June 28, 2007)
While noting that "growing evidence supports that physical restraints have a limited role in medical care," this letter clarifies the phrases "remove easily" and "freedom of movement" as related to physical restraints. It further clarifies the meaning of "medical symptom."
42 CFR 483.13(e) provides that "the resident has the right to be free from any physical or chemical restraints imposed for discipline or convenience, and not required to treat the resident's medical symptom." CMS defines "physical restraints" in the State Operations Manual, Appendix PP as, "any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body."
The following clarifications are made:
"Freedom of movement" means any change in the place or position for the body or any part of the body that the person is physically able to control.
"Remove easily" means that the manual method, device, material, or equipment can be removed intentionally by the resident in the same manner as it was applied by the staff ... considering the resident's physical condition and ability to accomplish objective...."
While the definition of "medical symptom" has not changed from the current State Operations Manual, additional guidance is provided. "Medical symptom" is defined as an indication or characteristic of a physical or psychological condition. According to the CMS letter, objective findings derived from clinical evaluation and the resident's subjective symptoms should be considered to determine the presence of a medical condition. The resident's subjective symptoms may not be used as the sole basis for using a restraint. The symptoms should not be viewed in isolation but rather in the context of the resident's condition, circumstances, and environment. While there must be a physician's order reflecting the presence of a medical symptom, CMS will hold the facility ultimately accountable for the appropriateness of that determination.
Before a restraint is used, the facility must determine that the resident has a medical symptom that cannot be addressed by another, less restrictive intervention and that a restraint is needed to treat the symptom, protect the resident's safety, and help the resident attain or maintain his or her highest level of physical or psychological well-being. Physical restraints may also be used when they are "immediately necessary" to prevent a resident from injuring him/herself or other and/or to prevent the resident from interfering with life-sustaining treatment and no less restrictive, less risky interventions exist.
Note: Falls do not constitute self-injurious behavior or a medical symptom that warrants use of a physical restraint.
The information contained in the letter must be implemented within 30 days.
Jane Perkins
(919) 968-8855 (F)
perkins@healthlaw.
http://www.healthla