Joseph M. Bestic, NHA, BA Director, Nursing Home ·Health Services Advisory Group of California, Inc.

As many of you are aware, Health Services Advisory Group of California, Inc. (HSAG), the Medicare Quality Improvement Organization (QIO) for the state of California, is currently leading a project (Phase-One) to reduce the use of physical restraints and the prevalence of pressure ulcers among nursing home residents. To kick off the current three-year QIO quality improvement cycle (August 2011–July 2014), the Centers for Medicare & Medicaid Services (CMS) selected 142 California nursing homes for HSAG to engage to improve their physical-restraint and/or pressure-ulcer rates. In order to qualify for the project, nursing homes had to have a Long Stay High-Risk Pressure Ulcer rate of ≥ 11 percent and/or a Physical Restraint rate of ≥ 4 percent. This was based on a combination of Q4 2010–Q1 2011 Minimum Data Set (MDS) 3.0 data.
 
As efforts are underway to work with these nursing homes to improve their quality measure outcomes, many challenges still exist to reduce and/or eliminate the practice of physical restraint utilization. According to the CMS RAI MDS 3.0 Manual,1 “Growing evidence supports that physical restraints have a limited role in medical care. Restraints limit mobility and increase the risk for a number of adverse outcomes, such as functional decline, agitation, diminished sense of dignity, depression, and pressure ulcers. Residents who are cognitively impaired are at a higher risk of entrapment and injury or death caused by restraints. It is vital that restraints used on this population be carefully considered and monitored. In many cases, the risk of using the device may be greater than the risk of not using the device. The risk of restraint-related injury and death is significant.

 
As per Federal nursing home regulation F-221, a physical restraint is “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” (42 CFR 483.13(a)).2 F-221 requires the nursing home to secure a physician order including the medical symptom being treated and the use of the physical restraint.
 
When an attending physician is presented with a request by the nursing home to order a device to physically restrain a resident, the following should be considered:

• What type of behavior is the resident presenting?
• What is/are the root causes of the behavior (UTI, TIA, etc.)?
• Has the nursing home staff attempted restraint alternatives?
• Is the resident in pain, hungry, thirsty, tired, or in need of using the rest room?
• What may be deemed as a “behavior issue” may in fact be the only way a nursing home resident with dementia can communicate his or her needs!

Physical restraint utilization should only be used as a last resort after all other options have been attempted and care-planned in the resident’s medical record. As mentioned above, risks of utilizing physical restraints with nursing home residents can far outweigh any benefits. To learn more about physical restraint reduction, including supportive literature and evidence-based best practices, please feel free to contact Joe Bestic, NHA, BA, HSAG Nursing Home Director, at [email protected]

References:

1. Centers for Medicare & Medicaid Services. RAI MDS 3.0 Manual; CH 3: MDS Items [P]; pg. P-2.  Available at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html.

2. State Operations Manual: Appendix PP—Guidance to Surveyors for Long Term Care Facilities.
Available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

This material was prepared by Health Services Advisory Group of California, Inc., the Medicare Quality Improvement Organization for California, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. CA-10SOW-7.2-091912-01