And now, I would like to introduce our speaker to get us started. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. 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. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPIC, she served as the Director of Western Region Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regents University, a Doctor of Jurisprudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. Thank you for being here with us this morning, Laura, and we invite you to go ahead and get us started. Okay. Thank you very much, Lindsay, and welcome, everyone. Lindsay mentioned this is a very interesting topic that we're talking about today, and that's restraint seclusion. It is probably one of the most problematic, meaning most cited deficiency within the manual with CMS and other accrediting organizations. So that's why it's nice that Georgia Hospital Association is providing you with this information. Speaking of which, this information that I'm presenting today is strictly that, informational only. It is not intended to serve as legal advice or establish any attorney-client relationship. So please, please reach out to your in-house counsel, legal representative for direct advice, especially as it relates to situations that have occurred within your hospital. I'm going to do a quick introduction on why we are here today, and that's for those of you who've gone through surveys, this is something you don't want to get, and that is a statement of deficiencies and when you have to submit back that plan of correction. No facility, no provider ever wants to get noticed that they have been involuntarily terminated from the Medicare and Medicaid agreement that poses such a huge financial impact to a facility or a provider, and again, that's just something we desperately want to avoid. Something else we don't want to see are some headlines, and especially as it relates to maybe our facility. And these happen to do with restraint, seclusion, and patient injury as a result. This one happened to be where we got a young lady who was admitted for depression, paranoid ideation, et cetera. She was admitted to the hospital, and they unfortunately found her face down in the room, motionless, and died during a restraint where she was there. Here we had a gentleman who happened to die, he was face down, he was combative, no question about it, but he was put face down on the cart and put in restraints and essentially suffocated while he was there. And it's a situation we had here in our state, my state of Colorado, where we had patients who died as a result of that prone restraint technique, and it was very similar to what you just saw in that last slide where the patient is face down, and it's almost an asphyxiation due to the restraint of their ability to breathe. They maybe get their face turned, but also chest, they can't get their chest to expand. In March of 17, there was an article out about a Greenville hospital where they lost their contract, they lost their Medicare agreement because they had deficiencies, where they had a young gentleman, 48, he was strapped to a gurney, traumatic asphyxiation. Here the coroner went so far as to list this as a homicide when he came in for a gunshot wound to the arm, and of course he struggled, that's why they put him down. Another one, same situation, here's where a patient, South Carolina Hospital, face down on a gurney, traumatic asphyxiation. Pennsylvania Hospital, they got cited because multiple issues where the use of restraints and really not very tight policies when it comes time to suicide. They weren't able to say, why is this patient being restrained? Nobody could answer that, no documentation, they didn't start out with the least restrictive methods first. Then they had situations within their hospital that posed a suicide risk, grab bar, doorknobs where a patient could hang themselves in them. In fact, even some of the courthouses, by the way, if you go into some of the public courthouses now, you won't find coat hooks on the back of the doors because it poses a strangulation risk. This happens to be that article regarding the Pennsylvania Hospital. Here we had this, unfortunately again in my state, where we have a facility that takes care of adults and children with developmental disabilities. Here patients were being restrained for up to eight hours, and it was almost a convenience method. That's why they cut their funding, and that was huge because all of these patients, majority of them were on Medicaid. That's why we now have to start rethinking the use of restraints within our hospital. This study showed it increased the risk of delirium by fourfold, and pressure ulcers, respiratory complications, again, that asphyxiation where they can't expand their chest. Health and Human Services study, 40% of hospitals, they're not reporting these deaths as they are now required. By the way, we're going to talk about that issue as we go through here. Now we've started to rethink the use of restraints. One thing they found in August of 16, well, they found they were less used when you have more nurses, and particularly RNs, because they found out restraints can lead to confusion, agitation, some other really bad health effects. By the way, if any of you have ever tried to feel what is it like to be in those restraints, you'll find how it can make you extremely agitated because you can't move. Unfortunately, some hospitals have had to compensate with their shortage of RNs by increasing the use of restraints, and then, of course, the quality of care does happen to go down. It also looked at data from almost a million patients, 870 some hospitals in the U.S. on MedSurge. This was part of the national database and the nursing quality indicators. 1.6% patients had been restrained. Over half were restrained to prevent falling. During the study, the use of restraints did drop 50% because they found, again, the more RNs, the use of restraints dropped also. Why was that? Well, because they were better trained to find alternatives to the restraints, seclusion. Granted, they get more opportunity for that education than, say, your licensed practical nurse or even an aide. So they have that opportunity to get that benefit of that education. Overall, it's just not how many you have on staff, but having adequate number of RNs. I understand that may sound a little unrealistic with our shortages in some areas, especially in behavioral health, but again, this is what that study happened to show. A more recent study back in 22, they looked at three topic-based focus groups. 19 of those participants came from nursing, physical therapy, and then medicine. What they found was we really didn't have good hospital guidelines and documentation very lacking as far as the effect on did this really improve or help with that patient's behavior. They were described and listed as a safety measure, and using them was more often led by the nurses. And so they found that those attitudes and experiences, well, that were the main detriments for using those restraints. Experienced nurses, believe it or not, used them less often. Those who had prior experience with violence, and we know that's a big issue now, violence in the workplace, they were increasing in that use. So let's go ahead and start. These are what's called the conditions of participation. And the conditions of participation is just what do you have to do in order to be a part of the Medicare and Medicaid program? They put out the rules, the Health and Human Services, they put out the rules, and it starts in the Federal Register. Well, then CMS, who's under Health and Human Services, they have to publish that regulation out to their surveyors and everyone else, and that's in a transmittal. They also have to develop interpretive guidelines and survey procedures. The guidelines tell the surveyors, hey, this is what we expect to see, the rationale behind it. And of course, the survey procedures are this is what you're to look for. And they're also responsible to update the manual. Three types of surveys, certification, complaint, and validation survey. So how do we keep up with these changes? Especially with Appendix A, there have been over the last four years, three major updates. And what you want to do is first off, subscribe to the Federal Register. I have the links on here for you. Make sure you have the most recent manual. Again, your last manual for Appendix A, acute hospitals, came out just this year. So it's very, very recent. If there is a new manual, look to the transmittal page. I will show you what these look like, by the way, as we go through. And then check the survey and certification site monthly. That's more than sufficient. I check it daily, just to make sure there's not something that slips in there. But monthly is more than efficient. This happens to show you, this is on slide number 26, shows you the entire appendix for what CMS has responsibility to prepare guidelines, publish the regulation, and then survey procedures. And we're going to focus on Appendix A today, because that's where these regulations are. If you are a critical access hospital and you are listening, yours is W. You also want to keep in mind one other manual in here. That's Q. That's immediate jeopardy. Keep that in your library close. Because if CMS comes out, or one of the accrediting organizations comes out, they find something very concerning, or they get a complaint that could rise to the level of immediate jeopardy, in other words, jeopardizes the health, safety, or life of a patient, you can expect a knock on your door within usually two business days. The operations manual for acute looks like this. And you'll see, again, the last issue date was in April of this year. The transmittal page that I mentioned, you will see this in blue lettering once you go to the manual. When you click that item, and that's, by the way, for Appendix W, you'll go to this page. And this will just tell you these are all the changes in a nutshell. To get to those changes quick, click on where it says revision number. And that's just an example on what it looks like. Number slide 31. You'll see what's revised, what's new, or what's been completely taken out. Again, major, major overhaul in 20. Some updates in 23. And then for you, your last revision and updates was just April of this year. For the memos, and this is where they send out notices. Hey, this is new. Go pull it down and pay attention to it. And that's an example of what it looks like. So we talk about this in another session. But that's the ligature risk assessment that you must perform within your hospital. Now, they understand, just briefly for this memo, they understand all hospitals are not created equal. You may have different types of patients. At different times, you may have more risk for ligature and patients harming themselves. And that's why it's important to do that assessment. By the way, if you ever want any of these memos, I try to put them in the appendix so you can go find them. Deficiencies. Mentioned that this was the most problematic area in the manual for deficiencies. If you're trying to find out, okay, where do we stand? And maybe you're new to your role. You can get access to that data. And it's also a good way to benchmark for what's going on in your community. But what you would want to do is go to this site here. I've got the link there on slide number 36. Scroll to the bottom where it says hospitals. And you will see the full text statement. That will take you to another page. You've got two Excel documents. One is from the beginning to 2016. The second document is more recent. That takes you from 2017 to current. And that's what will pop up. You get a large Excel format. Now, I just happened to highlight the deficiency tag column because that's how I research out, okay, how are things going? What's been different? But include the letter. That's your appendix letter and the four-digit number. And so, again, that will take you to what you have to see for restraints. Now, I've just listed out some of these on what were the more recent ones. Why are hospitals getting cited? Well, first off, they don't follow their own policy and procedure. They didn't contain. The policy didn't even have any reference to what the requirements were under the manual. They didn't teach restraint training. That is a requirement. In fact, this is the one requirement in all of the required education in the manual where you must train your staff before they apply or remove restraints. That's spelled out in the manual. They didn't have a policy on defining seclusion. They didn't complete written modification plan of care after they put the restraints in process. Orders weren't renewed as required. They didn't release a patient at the earliest possible time. Not documenting restraint. Monitoring for nonviolent restraint as according to their policy. Now, I first said no policy and procedure. Well, that's not good. But probably worse is if you have the policy and your staff isn't following it. It's there for a reason. Not getting an order. That's probably one of the most cited issues in this whole section. Physician didn't do their required face-to-face assessment. They put a patient in a quiet room, also known as seclusion. No order. No documentation. And then finally, they didn't do a debriefing. Now, the hospital policy required that. CMS, Joint Commission, you don't have to do a debrief. It's not required. But their policy said they would do it. Order wasn't written by a provider who even had privileges to do it. Attending wasn't notified when they did put the patient in four-point restraints. Not enough nursing documentation. And then they just simply didn't monitor the patient or do any safety checks. So you can see they really are focusing on that patient safety for these. I did mention the complaint manual. And so there is a process when they do have a complaint involving restraint seclusion. And if you don't comply, you don't remediate those deficiencies, you can be terminated. But then to add insult to injury, OIG, Office of Inspector General, can come by and issue a monetary fine. CMS can't do that. They can, again, terminate the agreement, ask for payback, but they can't issue a fine. So as far as death and reporting, I'll cover this further later, but just very briefly. This is in the complaint manual. This applies to all deemed, non-deemed hospitals. And what they're referencing here in particular are those critical access hospitals who have distinct psychiatric units or rehab units. And I just want to point out, if you are such a facility, you are surveyed under Appendix A. That part of your hospital is not surveyed under W, rather A, and that's what you're expected to meet. Also, you're required to report the death that is necessary. You report it to the regional office, not your state agency. And you have to do it electronically. You can do it by fax, email. There is a form. I have it in the appendix for you on how to complete it and what is required. But overall, the regional office will evaluate the form. They'll decide whether or not there's been a violation, also known as deficiency, within the tag numbers we're going to cover. And they are the one to say, OK, state, you need to go in and investigate. And again, within two business days, they'll be there. And also, they will notify the protection and advocacy organizations if there is agreements in place for those. So you have to report death, just briefly, if the patient died in a restraint within 24 hours of being restrained or if they died within seven days. And it's reasonable to believe that the restraint, the use of the restraints caused the death. Now, there is an exception where you have, say, your ventilated patients. Maybe you have them in the soft wrist restraints. And the cause of death was not because of the restraints. It was because of their underlying illness. So here's just some information you're going to need for that TIN 455 form. Maybe you want to print off this, but this is what you have to include. Diagnosis, cause of death. Why did they get into restraint and or seclusion? And then how was that associated with death? Those are just some of the key issues that you'll need to know for that. All right. Well, let's go and start with Appendix A. There are 50 some tag numbers for this. It's the largest component within the entire manual. It is, and again, an acute hospital Appendix A. There's additional tags that talk about death reporting and training. But 50 pages of standards. Critical access hospitals. Again, there's no corresponding section within your manual that talks about patient rights as it is with the acutes. The only area it is in is in your swing bed section. But you still have to do something. I mean, you folks still get patients into the ER. You have patients who are combative or maybe have behavioral health issues. So you still have to do something for them. And you can adapt some of those standards. But if you do have those distinct units, you must follow Appendix A. That means you have to have policy and procedures on restraint and seclusion. And so for those hospitals, criticals that do have especially distinct units, they just, of course, they have to follow within A. But some have just taken on for it anyway. I want to start with seclusion. Yes, this is out of order. But there's only one tag number that talks about seclusion individually. And Lindsey did mention we have some questions throughout here. And so I'm going to start with this one. Lindsey, would you put that up for me? I sure will. And actually, I'm going to read this first part. And then I'll put up the question here at the end here. So it says, Alpha Hospital provides inpatient care for behavioral health patients of all ages. Eric is nine years old with autism and frequently disrupts the unit with yelling and throwing objects. Also on the unit is Brent, who has a history of initiating fights when there are loud noises in the environment. One day, Eric was heard yelling in the common room, at which time Brent started shoving him. Hospital and unit policy calls for seclusion when one patient exhibits confrontational behavior. And then the question is, should Eric or Brent or both be placed into seclusion? And so you see your options here now on the screen. Eric, Brent, or both. And for those of you who may have just recently joined us, I will post the link to the slides there in the chat. I did see that question come into the Q&A. And then as we go throughout the presentation, there will be several of these polling questions that you'll have the opportunity to answer. And we will also take some time to address your questions for Laura up to that point in the presentation. So if you have any, go ahead and be typing those into the Q&A option found there at the bottom of your Zoom window. Or if you don't see the option for any reason, you can, of course, utilize the chat to type in your questions for her as well. And we'll pause to address those during the time of the polling questions throughout the presentation this morning. Okay, looks like we've gotten a pretty good response here. I'll go ahead and end this and share that result. Okay, so Brent, Eric, or both? Yeah, this was a tough one, tough call for him. Eric had this underlying issue, and it was like, okay, how do we handle it? And so they chose not to put Eric in seclusion. Brent, they did have him kind of do a, quote, timeout, which got real close to seclusion. And so they did separate them both, get them back to their rooms, get them calmed down and quiet. Does that rise to the level of seclusion? Yeah, probably it would have, but how did they handle this? Well, what they ended up finally doing is making sure they were not in that room at the same time because Eric couldn't control his, he couldn't control his outbursts. And of course, Brent, that's how he responded. Oh, excuse me. So the definition of seclusion, involuntary confinement alone in a room or an area where they are physically prevented from leaving. Now with Brent in that situation, they told him he had to stay in there. They wanted him to decompress and get back in it. And when he tried to get out immediately, one of the orderlies were there saying, no, you still need a little time out. So his was technically seclusion. Now with Eric, he wanted to stay in the room. He wanted to be away where there was quiet and he could just be focused and they got him redirected and he was fine. They didn't prevent him from leaving. So was his now? Should they both have been? Yeah, maybe. It's only used for when you have violent or self-destructive behavior. Eric didn't have that. That was his. Brent did because this definitely jeopardized the safety of others. Not just Eric, the other patient, but the staff and there were some visitors in there when he started shoving and doing that. This is the only tag number again where seclusion is identified separately. What's not seclusion? Locked unit with others, putting in timeout, or saying, we want you to stay here within the lobby. Just kind of walk around, stay here. What they have found is by reducing the use of seclusion, it kind of helps. It helps patients not feel so penalized, so to speak. There are tools that you can use. It's called learning from each other. Back in 03, it has not been updated, but really good societies put this item together on how we can maybe decrease that use of seclusion. Yes, there will be times you absolutely have to do it for the safety and wellbeing of others. So it's not saying no, never use it. It just maybe there are other options. Well, let's go ahead and start with the meat of this. And that happens to be restraints. And I'm gonna go over the standards and guidelines. Overall, again, it's in the patient rights section. It is the largest part of the manual. And this applies to everything, our hospitals, locations, and patients. Now, joint commission calls them behavioral health, non-behavioral health, like medical surgical patients. CMS refers to them as violent and non-violent or non-self-destructive patients. So overall, in the patient rights, patients have a right to be free from unnecessary physical or mental abuse and corporal punishment. And that's how they list restraints, corporal punishment. You only use it when you absolutely have to. It's for safety. It's not discipline, it's not coercion or convenience. Again, as my facility here in Colorado, they used it for convenience. And then of course, stop as soon as you can. The key behind here is the assessment. We must do a comprehensive assessment with this person. Are there underlying medical issues that could be causing this behavior? Hypoxia, low blood sugar, electrolyte imbalance, or even drug interactions. Had a good friend who was extremely ill. She was septic shock. And she recalls after her recovery having paranoid ideation and that she would lash out to protect herself. She couldn't control it. She didn't know what was going on at the time. That's why they had to do that underlying assessment. It must be ongoing because what you're trying to do is get the patient out of those restraints as soon as possible. As far as your decision to use them, whether it's restraint or seclusion, again, that's based upon the individual's assessment. Also, are there something or items that are least restrictive that maybe would pose less of a risk than using the restraint seclusion? Don't forget that physical exam to rule out that underlying issue, electrolyte imbalance, for example. The use is not driven by the diagnosis. Paranoid schizophrenia, that's not enough to put a patient in restraint. It's only, only when that unsafe condition continues. So there could be multiple reasons why you need to use them. And here's just some that CMS has mentioned. Maybe they're causing themselves harm, self-injury. They're combative, throwing things, trying to take out medical devices. Those of you who've worked in ICU and CCU or even where they're waking up and they try to take out the ET tube. You need to make sure that we keep those items in place. One thing that CMS has stressed continually throughout the manual is the responsibility of our leadership, of the C-suite, the CEO, et cetera, because they are responsible for that culture that really supports those patient rights to be free from unnecessary restraints. So what they have to do, what their responsibility is to make sure you have systems and processes to eliminate inappropriate restraint seclusion. They also have to make sure that the use of restraint seclusions are assessed and monitored through the QAPI process. They're only used for safety and that we are complying as a hospital, they comply with all of the requirements for restraints and seclusion. One of the articles I mentioned earlier talked about falls and CMS stresses that the use of those restraints should not be a part of your routine falls prevention program because there's no evidence that stops them, that it prevents it. In fact, they can result in more severe injuries. Patients, older patients, say for example, get a little confused, they try to get out of bed, they're in a restraint and they get caught, fall, crack their head, break a leg or even worse, strangulate themselves. They have shown reduce the risk of restraints may decrease the risk of falling. And just because a patient might fall, well, that's not sufficient, that's not an adequate basis on its use. So that's why it's so important to do that assessment. If something underlying that really prevents a patient from walking or getting out of bed safely, history of falling without enough basis in their clinical assessment, that's inadequate to demonstrate that we need to put them back in those restraints. And of course, convenience is never acceptable. And it cannot be substitute for adequate staffing. That was one of the problems with our facility with developmental disabilities. They were really short staffed, they were. And so that's why they were leaving them in restraints. So here's what you wanna find out. And this happens to relate to falls. Is there any way for the patient to get up and walk around safely? Yeah, do they have a walker, somebody with them, assistive devices, maybe even a wheelchair that they can hold on to? Other interventions that prevent them from slipping or tripping? A medication, if that's what's causing that unsteady gait. Again mentioned, can someone go with the patient? Doesn't have to be a nurse, can be a tech, can be a family member. Or do we need to move them closer to that nurse's station to keep an eye on them? On the medical condition, if your assessment shows that we have to protect the patient from harm, use that least restrictive intervention. You can consider restraint. They're not saying no, never, ever. You can, but maybe there's something less. What is the risk? Weigh that risk of using the restraint against what's going on with that patient's behavior. And I always think of sundowners here. You know, sometimes it's okay that they get up and walk around at night, walk the halls. Just keep them active and keep them safe, of course. We have a request from the family to restrain them. Nah, it's not enough, that won't fly. And if you do have that need, the practitioner, the provider, they have to determine what type that has the least risk, but yet the most benefit. And of course our documentation, that's so crucial. We have to demonstrate that what we are using is the least restrictive. Protects the patient, and it's all based on upon our assessment. Those assessments, they have to be ongoing and show that continued need. Once a day may not be enough because they could change over time. They could wake up during the day, or maybe they get a little cranky in the afternoon and they start getting up, walking, being inappropriate. That's what we have to assess. Yeah, I love it in here. CMS actually puts into the regulation a discussion on the use of weapons. And they're here in particular, that's when we're trying to apply the restraints or put a patient in seclusion. They find that is not okay for healthcare providers to use. And they list them out, whether it's a taser, a stun gun, I can't believe they actually put in cattle prods, but that's in the list. Yes, it is. Now security, they can carry according to what their policy says and what the state and federal law allows them to carry, because that is not a healthcare intervention, that's law enforcement. CMS simply does not support the use of weapons as a mean to subdue a patient to place them in restraint or seclusion. And there are certain things in this law that are simply not covered. And that is those that address law enforcement, handcuffs, shackles, non-employed personnel, contracted law enforcement. These are folks who are not your hospital staff, because again, it's not safe nor appropriate. The idea here is that if law enforcement brings them in, they're in custody or detention, and they're doing it because of the public safety. And so again, this rule does not apply to those type of restraints. Just make sure your policies are clear on who does this and when does law enforcement step in and when does your staff then step in? They also mentioned the restraint chair that they utilize. This is when we have to transport a patient to and from the hospital. Again, this is the emergency restraint chair and law enforcement puts that on. So what's the surveyor going to do? Well, first off, they wanna look at your policy and procedures. They wanna find out who can discontinue and the circumstances under who can discontinue restraint and seclusion. They will look at medical records where restraints have been applied and used on non-violent, non-self-destructive, that's your ICU patients. When you do have those violent or self-destructive patients and you had to use one or both, and those who are currently in restraint or seclusion. So there's gonna be a host of records that they may be reviewing. They want evidence that staff identified the reason for their use and that less restrictive simply didn't work. They'll talk to staff. What's your understanding of the policy for restraint seclusion? And if you do have a patient currently in restraint or seclusion, they wanna find out what is the rationale. When did you last go check on that patient? What was the components of that assessment? Because they're trying to make sure that the actual use is consistent with your policy and procedures and that it's compliant with the regulation. They will look at your incident reports where there were injuries involving restraint or seclusion. And are there incident reports that are more frequently completed for such patients than other patients? What injuries were sustained? What'd you do to prevent an additional injury? And did you investigate? Maybe there's something we need to change in our policy and procedure when a patient was injured. They will look at data in a timeframe, maybe three months. Because what they're looking at is, is there a pattern to the use? Is it on a unit? Maybe it's a day of the week. Was there an increased use? Maybe that wasn't based on the patient's need. Is it because staffing was low or staff didn't have the benefit of the training? And then they wanna also see your schedules because was there a difference in the schedules and the use of restraint? But the surveys don't stop there. They go and talk to patients and those who happen to be restrained. And primarily those non-violent, non-self-destructive behaviors. Was there an explanation given to them for the use? Was it given in ways they could understand? And can the patient articulate their understanding? Now granted, the patient may not remember that. And that's why it's so important each and every time that we have to put them in or leave them in to explain it to the patient, or at least if they have a visitor there. It's here because she subconsciously goes to reach her endotracheal tube and we can't have that. She needs that to breathe. CMS does provide us some definitions. As just a side note, when you're doing your policy and you're looking for a definition, I would use CMSs also. It's a physical restraint. Anything that, whether it's physical or mechanical material, a piece of equipment that immobilizes or really cuts down the patient's ability to move arms, legs, head also freely. And it applies in all settings and all uses. It includes medications. And that's when it is used to manage their behavior and restrict their freedom of movement. Now, be aware, this is not all of those psychotropic medications. They're talking about those that are not a standard treatment or dose for that condition. PRN standing orders, they're only prohibited if it's used as a restraint. For example, Phenergan used to be used to kind of chill patients out because it had that ability. Well, that's not what it's for. It was for nausea. So that would be considered a medication used as a restraint. Again, it is not meant to interfere with treatment for a serious mental illnesses or when they are necessary to really help them function, to help that patient function. Now, the criteria you wanna look at is, is this medication used within those pharmaceutical parameters that FDA has given approval to? And also that the manufacturer said, this is what it's made for, this is how we're labeling it. And these are the dosage parameters. Of course, it follows all of those practice standards and it's used to treat those conditions. Again, we really are trying to help with that patient's functioning. Appropriate use, it helps them be more effective, more functioned effectively than they would if they didn't have the medication on board. So what do we have to do? We have to do that assessment. Are there other types of interventions before we use that restraint? And again, they have certain examples in the guidelines. So let's say you've got a patient who is in detox and they become very violent, maybe aggressive. You can use that medication to address those outbursts. Again, it's when the medical community and research has shown this is effective to help them function better. Then there's the inappropriate use. Clearly, clearly not within the standard for that situation. It's not medically necessary, rather discipline or convenience. So when you have that patient who has sundowners and we're giving them medication to sedate them, keep them in bed at night. Well, that's not the appropriate use for it. The surveyor will look at your policies, your procedures. Do you have a written description of what is a restraint? Does it follow it? That's why, just take it right out of there. What constitutes a medication as a restraint? They will see and observe if you are using restraints and they wanna check and see what the documentation says. And then they'll talk to staff. What's the definition of a restraint? Can they identify when a drug then flips over to becoming a chemical restraint? And now question two, Lindsey. Okay, let's get that one up here on your screen. Okay, this one should now be on your screen that says, in our facility, restraint and seclusion are rarely utilized, sometimes utilized, never utilized, overused, or not sure how often or if ever. And then Laura, it looks like we do have just a couple of questions that have come in here to the chat. This question asks, what documentation must be present in order to justify the reason why the patient is alone? And we talk about, oh, being alone. It would be, again, take your definition and does the patient, are they throwing things? Are they being violent? Are they being aggressive? Are they pushing, shoving, whatever it is so that you have to get them out of that environment and put them into a safer one and be as descriptive as possible. Doesn't say patient seems angry. That's not descriptive enough. Whereas patient is grabbing the chairs and throwing them across the room at other patients. Patient picked up a plastic water bottle and threw it at a patient and then charged this individual or the staff. Descriptive behaviors to show, hey, this meets our definition and our criteria that seclusion is necessary. And so CMS won't give you any really good definition. They leave that again to the professional societies to spell out. What did you observe that qualifies for that behavior to need necessitate seclusion? And then this next question is pretty similar and you probably just answered a good deal of it, but it asks, please clarify the definition of seclusion regarding a room or area where a patient is prevented from leaving. I assume that a secure or locked unit such as the psychiatric unit or behavioral health unit would not constitute the intent of a room or area for seclusion. Is that correct? Yes, that is correct. Correct. Just being on a locked unit doesn't count. No. Okay. And looks like this is the last question that says in hospitals, do you consider sitters for patients as seclusion since a staff member is usually sitting at front of the door or to monitor the patient closely, but presence of a staff member could give the patient idea that we are preventing them from leaving the room. And that's where, yeah. And that's very light. That's very, very possible. You just have to explain to the patient, we're just here so you don't fall and hurt yourself. We're here to assist you in that situation. Because yeah, sometimes that's a very fine line when sitters are there. It's like, no, no, you can't leave. So what is the purpose behind that sitter? Normally it's just there to sit with the patient and make sure they don't get out of bed and hurt themselves. They can help them to the bathroom. They can help them walk down the hall then get out of the room. That's fine. But it's when they are prevented with the use of that sitter from leaving. And that's where you do have to follow the requirements. That's a very good point because one of our sons was, he was a CNA here and he was placed in a room to prevent the patient from leaving. And that qualified as seclusion. And he was concerned because he didn't know about the documentation, whether or not the staff had documented the reason behind him sitting there and preventing the patient from leaving. That is seclusion. That was kind of a fine line there. Okay, I'll go ahead in this poll and share those results. Okay, yes, sometimes and rarely, great. Okay, so what's not a restraint? These are those devices, bandages, inprotective helmets. Those of you who probably worked with folks who have seizure disorders and they wear a helmet, that's not considered a restraint. Holding a patient for an exam, like when we used to have to hold them for the spinal taps, that's not a restraint. Anything that could help the patient still participate without the risk of harm. IV board is not considered a restraint, of course, unless you tie it to the bed. Then it is a restraint. Side rails, those for padded for seizure precaution, stretcher on a narrow cart where you put up the rails, those are not restraints. Those that, when you have that bed that continually moves, because you wanna make sure that first off, the mattress doesn't fall out and the patient doesn't go with it, those are not a restraints. If the patient's immobile or unable, just physically unable, they're paralyzed and you put the restraints up, so when you do turn them, that's not a restraint, the side rail, excuse me, but you can't use them to prevent them if the patient can lower, if the patient can lower the side rail and you put them up just like say three of them and they use the other two to help get up, that's not a restraint. All four are up and they can't lower it, it is a restraint. Those supports that we have them during surgery, that's not a restraint. I don't know why they felt they had to put that in. Usually if you're having surgery, you're out of it, so you wouldn't know it anyway. Those you use in recovery, they have to be medically necessary and that when you're holding a child to give a shot or a seatbelt across the wheelchair for transporting, that is still not considered a restraint. It gets a little murky when we're talking hand mitts. It's not unless of course it's tied or pinned down or it's so bulky, they can't use or bend their hand. So I've got an example of what is and is not considered a restraint. The one on the right, the one that looks like a boxing glove, that's a restraint. The one on the left, it's not a restraint. Now it gets close. They can still kind of move their fingers and bend their wrist, but see there's a little, they can still do that. So it's not considered a restraint. Other devices that are restraints, tucking those sheets in so the patient can't move. The net bed where the patient can't unzip and get out. Freedom split that immobilizes a limb. Side rails, again, prevent voluntary exit from the bed. Jerry chairs if they can't easily remove it and get out independently. So one of the examples that I mentioned here that was not a restraint where we've got the seatbelt that's going across their lap. Is this a restraint? And the answer would be no. The patient can remove that Velcro and get up. It's there to keep them upright within the chair and provide them some support. Other restraints, belts, jackets of course, ties, manually holding them to force medications, physical holds if they're violent or self-destructive. Now I wanna point out one thing. CMS isn't saying these are bad. You just have to be prepared to support why you had to utilize them. Age specific items that are or may not be considered a restraint, stroller safety belts, a raised crib rail. They have to be age developmentally appropriate and address those in your policy when you are going to use them. Holding an infant or a toddler, that's not considered a restraint. So they do give us some examples of what they are. What we're looking for is the least restrictive and they may only be used when those interventions just simply don't work. You know, when they can't protect the patient, the staff or others. You know, you've got a very agitated patient. They're scratching, biting, throwing things if they get a handle on it. Otherwise what you are doing must be the least restrictive. The interpretive guidelines kind of spell out, okay, where do we start? Because you have to do that comprehensive assessment. And what that has to include is that the risk of using restraint or seclusion is necessary. And it's outweighed by those risk if we don't do it. You don't always need to try them. You know, you may have a patient who just all of a sudden has a meltdown. And that you have to do it quickly. But again, your staff has to determine that normally what you would do is ineffective. It's not gonna work. Alternatives for not using FIN, you have to document it. If you are able, I mean, if you have time, the alternatives didn't work. We tried to calm them down, use that soft voice and became more and more agitated, picked up something, then you step in. The surveyor wants to make sure there's orders that specify the reason, the duration, the type of restraint and seclusion. Because what they're looking for is, is there evidence of factors other than the individual patient? In other words, the paranoia gets when you consider determining the causes for restraint and seclusion. Is there something going on in the environment? Remember that first example with Eric and Brent? It was loud noise. That's what set off Brent. They'll look at the records, documentation of that assessment. Don't forget to revise your care plan. Document changes in behavior. What are the staff concerns for safety? Is there an immediate danger? Now, some of your staff who work with these folks have a lot of good experience that they can share and says, I'm telling you, he's about to go off the end. Listen to him when they say those things. They want documentation that the least restrictive was considered and that they didn't meet those needs. Was there an ongoing assessment? You know, we went back and we checked this person after half an hour. If time is going to be extended for that restraint and seclusion, were the symptoms continuing? So you had to continue the restraint and seclusion. And was there evidence in the staff did evaluate the patient? That, okay, they're calmed down. We can take them out of it. That's where the plan of care is so crucial. They have to be used according to that written plan of care or any modifications thereof, including medications. It has to be documented. Modifications, they don't, you know, need not be made before you initiate or get an order for the restraint. In other words, you have to go change my care plan and then go get the order. No, take care of the patient first. Just make sure there is documentation to support what you did. Review it, update it in writing. Make sure your policy and procedures allow for that timeframe. Three days after the fact is not going to probably be consistent with the requirements. So I just put an example in here, the development of your plan of care, the key steps, and what are the key elements. Surveyor, they will make sure that what you do does reflect that loop. You assess the patient. You put the intervention into place. Then you went back and evaluated the patient. Nope, still going on. Or went back and reevaluated the patient. Maybe you took them out. Then you went back and reevaluated, still doing okay. They want evidence that assessment identified the program or there was evidence that you actually looked at the patient and assessed them. The plan of care reflect that assessment. What's the goal of the intervention? In other words, what did you want to get out of putting that patient in restraint? Who's responsible to put it into place? And did you inform the patient of the changes to the plan of care? Well, we have to tell them. They may not agree with it, but we have to have patient explain the purpose behind the restraint seclusion. 167 talks about the use and safe and appropriate techniques. Of course, follow any policy or state law that may be in place. That's where your attorneys, your state attorneys will have to help guide you on that. But of course, we can't use them as a barrier for care. Surveyor is going to look at records. Did you do the assessment? Was there any injury that happened as a result of putting those restraints on? Whether it's echemosis, bruising, hopefully not a fracture. Was it effective? And again, did you follow your own policies? A key issue and one area, they also know this was again, one of the major areas, the top-sided deficiency was the order, the lack thereof. You must have an order by a licensed practitioner or physician who is responsible for the patient and authorized not only by state law, but your hospital policy. So that means it has to be within their scope of licensure and the policy consistent with their privileges. And it used to be PAs, nurse practitioners, they weren't allowed under CMS to order them. With the hospital improvement rule back in 2020, they said, well, that's ridiculous. These individuals, these providers are really a core part of some of the staff that you have taking care of behavioral health patients. It says, well, they're trained, why couldn't they do it? And so CMS said, hey, as long as the state says it's okay and your board policies say it's okay, we're good with it. So again, it has to be someone taking care of the patient and authorized to do it. Your policies have to stress when it can be used in an emergency, who can order it? A resident can order it, but a medical student cannot because they are not licensed. But again, a resident can. Now again, protocols. These are protocols for the application and use of restraint and seclusion. Now, before CMS said, nope, we're not gonna allow that. Well, now they're no longer banned. But you can have it as a substitute for the order prior to initiating each episode. What documentation has to include with protocols is that you've done, it will include an individual assessment. What are the symptoms? What is the patient exhibiting? And what diagnosis resulted in the use of that protocol? Now, this is a very fine line. For me, it's a very fine line between a protocol and a standing order. So just make sure that your protocols are very clear and they're followed because the surveyors wanna see your policies on that. They wanna see the bylaws, practice guidelines, who can order restraint, seclusion. They will confirm if they actually spell out who can do this, who can also initiate restraints. They'll look at medical records. They wanna see that order. And they will verify that the provider obtained, got the order, you got it right away, like minutes when you had to apply it emergently. And are the protocols that you did utilize, are they consistent with that regulation? Now, that's why I always say, be careful when you're using protocols, standing orders, PRN orders. Orders for restraint should never be written as a PRN. Now, this is also spelled out in the medical records section. Ongoing authorization does not permit it. So you have to have that assessment. That means each episode must be initiated by an order. And when the intervention ends, patient's cool at that time. Well, if it comes back, you have to have a new order for that. Trial release, that's considered PRN use, and it's not allowed. Now you can take them out for, you know, if you give them care, turn them, rotate them, get them to go to the bathroom. That's okay. But a trial release, no, that's a PRN. The same for medication PRN use. Except three situations where you can have it. They're very clear on this. Jerry chair. If the patient has to have that tray locked in place when they're up and they can't get out without assistance. Number two, you've got side rails that are raised. And again, that's when the patient has to have them up and they can't lower them. You know, maybe it's those padded side rails or they're in that movable bed. And then it's a self-mutilating behavior like Leish-Nahum syndrome. If any of you've seen it, you probably know that's very important that we protect our patient. And I've just got an example here where that syndrome, the patient scratched away all of their cuticles and on their nails. And so they had to put them in mitts to protect them for that. You don't have to have a new order, but just keep in mind, this is a restraint. Next requirement. We have to notify our attending as soon as possible, especially if they didn't order it beforehand. Medical staff policy, they say, who is the attending? And what is the definition of as soon as possible? That of course is consistent. Not three or four hours, six hours later. That's not as soon as possible. In no event, and they spell this out, should it be over one hour. Why do we do this? Well, they're responsible for that patient's care. They have to know what's going on. They have to know we use the restraint or seclusion. It also helps continuity of care because there's that communication between healthcare providers. Make sure patient is safe, gets information, might help with the selection of what type of intervention. Now this notification can be face-to-face or over the phone because I'm gonna talk about when the physician actually has to come in, the provider has to come in and see the patient because of the use of restraint or seclusion. Each order is time limited. Four is for adults, two for children nine to 17, one if they're under age of nine. Now, if you have violent or self-destructive behavior, you don't apply when it's nonviolent, but for restraint and seclusion, these are the timeframes. That's violent or self-destructive behavior. If you're joint commission deemed status, it's exactly the same. What do you need to know? Maximum, these are maximum. So that can be shorter. The length of the order, that's the critical point where you have to have contact between the provider and the patient. The staff you are still, you have to continually assess and watch the patient. Maybe they come out sooner than later. And if you do take them out before that order expires, then you have to start over and get a new order. If so, the RN before that order does go off, RN has to contact the provider. Hey, this is what I found on my assessment and request the original order be renewed. It's up to the physician, the provider who oversees the patient. If we need to continue this ongoing assessment, the original order can be renewed for up to a total of 24 hours. After that, the provider has to come in and see and assess the patient before they issue a new order. This provider, and I'm only gonna use that jointly as a physician or a licensed practitioner. After 24 hours and before they write a new one, they must come in and see the patient. Your state law may be shorter. So check your state law to see if they have a shorter timeframe. They have to document what they see, maybe continue the use. And the surveyor is going to look for that documentation by the provider. Is the treatment planned? Is that address restraint and seclusion? Do we document how the patient is responding? Otherwise, you can determine timeframes for renewal. Make sure it's in your policy and procedures because the surveyor wants to see that. They'll interview staff, look at records. Is that practice consistent with what your policy says? Otherwise, discontinue at the earliest possible time. Doesn't matter how much longer is left on that order. Could be an hour, three hours. We only use it when that unsafe condition exists. Staff is expected to go in and check the patient. How are they doing on an ongoing basis? I've mentioned temporary release, that's okay. That's okay. If you have to get them up, go to the bathroom and put them back. What's not okay is a PRN, a trial release. Surveyor is going to talk to your staff. Do they know that, hey, we got to discontinue this as soon as possible. On the patient assessment, that has to be ongoing and monitoring the patient. Completed training according to what the criteria is. And the interval, though, is by your hospital policy. So what we're trying to do on training, an assessment, excuse me, is make sure that we're not harming the patient. How's their skin condition under those restraints? Do they have any issues with their coccyx? Are they getting skin breakdown? Policy, that's the intervals for your assessment. It's based upon the need, the condition. What type of restraint are you using? And individualized. What's their cognitive status? How are they, how's their condition overall? And are there any risk to continue with that type of restraint? This doesn't specify a timeframe. They don't, nor does Joint Commission. Some state laws will say, have a timeframe for just behavioral health units. You know, waking them up every two hours overnight could be a little excessive. When they're sleeping, let them sleep. It really depends on what is the patient's need. What are the factors? It could be every 15 minutes because they are so, so agitated and so sick. This is what your policy really needs to conclude as far as the content. And this is just basic nursing care, vital signs, hydration, you know, make sure they're drinking fluids or have some type of fluid replacement. That they can go to the bathroom. Skin, as I mentioned, you know, when they're squirming around and maybe they're a tad overweight, they could get some skin breakdown on their backside. What is that level of distress? Care needs, their nutritional, range of motion. Maybe it's evaluating, how are they emotionally? Are they just so withdrawn? Maybe it's time to reevaluate the use of that restraint or seclusion. That's what your policies have to address. Okay, up to the third question, Lindsay. Okay, I'm gonna read this first part and then I'll post the question up on the screen for you to have the opportunity to answer. This says, Hospital B recently opened a 10 bed behavioral health unit but has had difficulty staffing it with appropriately trained personnel. To ease some of the shortages, Hospital B instituted video monitoring for patients who are placed in restraints and seclusion. The monitoring room is at the nurse's station and the rooms are spaced throughout the unit. Will this be seen as compliant with CMS? And then I'll get this up on your screen here. So your options, yes, no, not sure, or possibly prefer not to answer. And then Laura, we do have a couple of questions here that have come in. And this first one asks, going back to the sitters conversation, more specifically sitters that sit with suicide or homicide intent patients on medical hold. As those patients are not allowed to leave the room, is that considered seclusion? That could be considered seclusion. If they're not permitted to get up and walk around and leave the room, they're prevented from leaving. Yes, that would probably be seclusion. Just again, documentation why it is so important for their safety. And if the policy states that they can leave the room to ambulate with security escort, in addition to the sitter, does that change to not being seclusion? It's getting close because why is security with them? Are they prevented from leaving the hospital, from harming themselves? Okay, because yeah, a escort could tread the line on being seclusion, could be. That's why your policy needs to be very clear and the staff have to understand the differences with just documentation. It's not necessarily a restraint, but it might be treading on seclusion. But again, that's in a confined area where they are physically prevented from leaving. Now they could probably dash out the door. They probably could with security. But if they are prevented from leaving the room, that would be seclusion. I wish they had a cut and dried answer for that. Sometimes it depends what the surveyor had for breakfast on whether or not they're gonna cite you on it. And then kind of along those same lines, what if they are in a room with security on the outside, but they are however allowed to have visitors? Oh, can they leave the room? If they're physically prevented from leaving the room, that could be considered seclusion. Just because they have a visitor, that's not part of the element of it. It's where they're physically prevented from leaving that confined space. And then the last question, okay, this follow-up here that says, no, they cannot leave the room. Okay, yeah, I think that would be considered seclusion. And that's why you need the documentation and assessment and plan. Why, why can they not leave the room? Remember, those who are in custody could be very different. You know, when they're there in a police hold, that's a little different than when they're in seclusion for behavioral health. I do wanna point out that difference. Perfect, and then this last question that I see here related to sitters says, if your facility uses sitters with these patients, are they allowed to document or does the nurse still need to document? It's up to you guys. The assessment has to be done by someone who's trained. Documentation be up wherever you want. That's what your hospital policy can say. You know, security can document, text can document, doesn't matter, as long as the policy and of course state law. But my state doesn't spell out who can document the record. That's up to the hospital. Okay, and then the last question I see here before I close out this polling question asks, if you could review again, if all side rails are up, if the patient is sleeping to prevent them from falling out of the bed? You have to just document why are the rails up? Can the patient lower it if they wake up and have to go to the bathroom? That'd be the big thing. Can they lower that side rail to get up to go to the bathroom? If so, not a restraint. Okay, that's the last question I see. We'll go ahead and end the poll and share those results. Okay, all right, and by the way, I'm gonna talk about this as we go along. Remember, I mentioned that one where they were using restraints because they didn't have enough staff. So, okay, so let's go ahead and move on. And we're gonna talk about location of rooms for these folks. So how much? Well, unless you're using both restraint and seclusion at the same time, you don't have to have a one-to-one observation. Unless of course your practitioner said, hey, this is necessary. Because the staff can also say, you know, this patient's made some really concerning comments. They're very combative, then okay. That's why if you are using both together, you don't have to have that one-to-one. You determine who does the assessment and monitoring, but just within the state scope of practice. Some states do not permit non-licensed assistants like CNAs, techs, however you call them from doing assessment. That's where you need your nurse to do it. But otherwise it could be on licensed staff for certain parts of it, like documentation. So the person who asked the question, very timely. But they have to know and be competent on what do you document? What are you looking for to document? The surveyor, of course, looking at your policies on assessment and monitoring. First off, have they been put into practice? Are categories who is responsible for doing this assessment, documenting, making the assessment, are they identified? Does the policy spell out how often we're going to give this person something to drink or get up and go to the bathroom? What they're looking for is a good reason, a valid reason for the frequency of that assessment and monitoring. Also documentation, does it reflect the patient's condition and the timeframes? Not only are they consistent with the policy, but documentation for those how many times, excuse me, that you are monitoring. Now I've just got some examples here. I don't endorse any of these examples. Just to kind of give you an idea if you want to start. These one, restraints for violent self-destructive behavior. And then the policy on it. What's included, what's not included. Items you want to document. This is what needs to go into the record. Skin condition, circulation, breathing. INO, how much do we offer them? Any injuries that they observed. Do we continue to need? What they're looking for is justification for continued use. Of course, we have to document their behavior. What did you do in that intervention for them? You know, when they try to jump out a window, that's a pretty good reason to put them in restraints or keep them restrained. Maybe they're trying to bite the nurse or they're picking up chairs, throwing them against the window. All of these, that's a safety threat. Not just to themselves, but to others. And that's why you may want to think about, if you're fortunate to have in your little toolkit, special forms. Because it will help make sure staff is documenting or looking at what they are to assess and how often they are to do that. You know, what type of restraint and what's the order. And then the physical restraint record. Again, I don't endorse any of these. Totally up to you on if you want to use them. If you had the benefit of the electronic record where it's easy to pull it in and incorporate it into the record, that might help. Because again, they really give alternatives in this particular form. Gives them an idea about what to maybe think about. I just have some suggestions here. These are not in the regulation. We know that we take action to improve things through our QAPI. Now leadership, they are supposed to assess and monitor restraints and seclusion. Remember, that was one of the highly cited deficiencies. So you might want to think about a log. If you have to put restraints in place, what shift was this happening? Was that particular staff? Date and time that you initiated? Was it two in the morning? Was there a full moon? What type of restraint? Any injuries to both the patient and staff? What's the age of the patient? It kind of helps you start collecting some data on the use of restraints and when they were necessary. How long did you have to keep them in restraints? They spell out here in the regulation training for the providers. These must be, this is a must, in the hospital policy. Essentially, your providers have to have a working knowledge of what that policy is on the use of restraints, seclusion, because they are the ones to order it. You do have the flexibility to identify the requirements based upon how competent is that provider? Do you have an advanced practice provider that really focused on behavioral health in their training? Same with the physician. How about the patient population that you are serving? Is there a high incidence of behavioral health patients, maybe older patients or those who happen to have early onset dementia? Training on use application of a restraint or seclusion, they usually don't come up in your med training. Maybe that's changed in recent times, but a lot of this doesn't occur in that. And then they also will look at credentialing and privileging files to see what's the training there, if that's what they're ordering. Which brings me to this one hour assessment rule. Now, when this first came out, it was met with a lot of pushback. And when the order first came out or the regulation first came out, what it was that the practitioner had to be in and see the patient with one hour of applying restraint and or seclusion. And the idea is that what they're trying to do is why are we doing this? They're doing this for the management of violent or self-destructive behavior. They found that a telephone call, even use of telemedicine, that wasn't permitted. It had to be face to face. Well, they made a big change in this. And part of it was because the pushback from the AMA and a lot of the other societies and professional societies. What it is now is this one hour can be done by, of course, the physician or an advanced practice provider, but can also be done by an RN. But these folks have to be trained. They cannot just be a nurse who happens to be on duty. They have to be trained. The nice thing is that if this happens again at two in the morning, the physician doesn't have to come to the hospital to see the patient. They can use a telephone conversation between the two, the person who's doing the assessment and the actual provider. But watch your state law. That could be a little bit more restrictive on who can do this. The face-to-face cannot be completed by telephone or telemedicine. So in other words, somebody has to go in and see the patient. A telemedicine is not enough. If the behavior goes away and you stop the restraint seclusion before the physician gets in to do the one hour face-to-face, somebody still has to go in and do it. It still has to be done because this really indicates something's going on that maybe we need to do with some prompt intervention and evaluation. Maybe we need to continue it. What contributed to that patient with that behavior was it appropriate to address that behavior? So what they're looking at, the factors they need to evaluate, what was the situation at that time? How did they react to the intervention once you put them in restraint seclusion? Of course, the underlying medical behavioral condition. Do we continue? Do we stop it? And training for an RN or a PA, they're in tag 194. I will get to those because some of them it's a little lengthy. What do you want to include? The overall assessment, both physical and behavioral. The review of systems, patient's history, the behavioral assessment, drugs, medications they're on or recently had, and most recent lab tests because what you want to do is, is there anything else that could have caused this behavior? A drug interaction. Maybe their electrolytes are way out of whack. Hypoxia, that's why you want to look at that underlying medical issue. Sepsis, I already talked about my friend who extremely ill with sepsis and how paranoid she became. Maybe we also have to document then our change in that plan of care and train staff on those requirements. They must know what to look for. So when you do use an RN who will then consult, if they are completing that one hour face-to-face, then they have to get ahold of that person who's responsible for the patient. Policy addresses that timeframe along with what is included. At a minimum, at a minimum, there must be a discussion of what the nurse evaluated. What were the findings of that evaluation? Yes, we need to continue this. And maybe it's like, okay, he's starting to calm down. She's starting to calm down, become more aware of the situation. I think it's time to take them off. And it doesn't need to be done prior to renewal of the order. Not, excuse me, if it is not done prior to renewal, it doesn't meet the requirements of as soon as possible. So again, the RN can go and assess as soon as possible, then get in contact with that provider. Using both together, restraint and seclusion, because I talked about this with that example. It's only permitted if the patient is continually monitored. So it can be face-to-face, but if not, then you have to use both audio and video closely to the patient. Because the idea is they can react quickly and continually means they're not off taking a coffee break. They are continually monitored, someone stepping in. Now, this doesn't eliminate that need from frequent monitoring and assessment. Just because you can see them and they're laying there, can you really assess how they are doing? And of course, maintain their dignity and privacy. So when they have to go to the bathroom, make sure the door is shut, or there's some, you know, that we maintain that privacy. If a person, you've got them physically restrained, they're in four-point restraints, they're alone in the room, they say that's not necessarily considered simultaneous seclusion. Because they do talk, maybe it's good to have them alone so they can help decompress. They're in restraint, yes, nobody else is in there, but maybe they just need that privacy, that quiet line, that quiet time. How do you distinguish it? If a patient can leave the room in absence of the restraint, they're not secluded. If the restraints were removed and the patient still was prevented from leaving the room, they are secluded. So the surveyor, they're gonna watch staff monitoring them, both video and audio together. Are they trained? Do they know what to look for? How close are they to the patient? Was there any interruption in that monitoring of the patient? Can they see every area of the room with that monitoring? Do they ensure privacy? So if the physician's in talking with that patient, make sure others around can't hear that conversation. How good is the equipment? Is it working? Is it a clear view? Is it a clear sound? Or does sound come in and out along with the visualization? Of course, we have to document and that includes our one hour face-to-face. What is the behavioral issue? What are the any medical underlying issues? What is the behavior? What's the description and that intervention you used? Did you try least restrictive? Was that, was that reasonable to try that least resist, excuse me, least restrictive before you did this? What conditions warranted it and how did the patient respond to it? And then maybe we need to continue this. These have to be in your policy and procedures. The surveyor looks again at records. They wanna see that documentation. Is there a clear description of that behavior? Was that intervention appropriate for that behavior? Documentation of least restrictive as appropriate and what was the impact to the patient on that intervention? So here's the one area, staff training and it's in tag 194. Patients have a right for a safe implementation of restraint and seclusion. That is why that plays such a critical role in helping actually reduce the use of restraints and seclusion. Staff must be trained and they must demonstrate competency before they apply restraints or seclusion. That is the one area in the manual where this must occur before patient care occurs. Application of the restraints, putting a patient in seclusion, monitoring the patient, assessing the patient and providing care. They're very strict on this one. And again, this has to occur beforehand. Orientation and make sure you're doing it routine throughout your policy. Those of you on medical and surgical floors where you're finding you're having to do this because you don't have enough beds, your staff still needs to be trained before that happens. All staff having direct contact. Yearly education, that's part of your annual skills. And don't forget your agency staff if that's what you're utilizing. Document their training and competency. You say the timeframe for ongoing. You may want it yearly because sometimes we kind of slip, we maybe bypass a step. So that's why it's good to have that annual skills. And of course, this is based upon what are your patient needs. Those who are evaluating the patients, and they spell out PAs and RNs. This is what they have to evaluate for that patient going to restraint seclusion. What's the situation? How are they reacting when you put them in restraints or seclusion? Underlying conditions. Continue or terminate the restraints, seclusion. Behavioral assessment, medications, labs, interactions, imbalances, hypoxia, pretty much an overall assessment of your patient. What are you looking for? What possibly could contribute to this? Now using of law enforcement or your security, it's not okay to routinely call on law enforcement to apply restraints or seclusion, not appropriate. Your security, other non-health staff can help direct care staff in doing this. Make sure your policy addresses it, but they must be trained and show competency in application. So if you are contracting with your security, make sure that they are trained and you have evidence of their competency, because that's all part of it. The surveyor will ask to see that. Which brings me to my third, excuse me, my fourth question, Lindsey. Okay, and again, I'm gonna read this top part and then I'll post the question up there for you all to select your answer. This says hospital D is in an urban area and frequently admits patients with underlying behavioral health issues. Lucy is one such patient with severe PTSD following an abusive childhood. This admission was for care due to self mutilation, ingestion of needles. On the second day, Lucy overhears a patient talking loudly to their child and she begins screaming and throwing items in the room. Lucy is subsequently subdued and placed in restraints. And then this asks, could hospital D be cited and if why? Let's get that question up here for you on the screen. Okay, and your answer's here. Yes, failure to adequately assess the patient or no, Lucy's response was not foreseeable. And then possibly failure to maintain safe environment. I don't see any pending questions at this time. So if you have any questions, you can go ahead and be typing those in. And for those of you who did submit questions, thank you. Because some of these are really fine lines and it's tough to say, but really if your documentation can support what you did and why, it may be good with CMS. You're gonna be ahead of the game for sure and this is why we had to do it. To protect the patient, protect the staff and visitors. Because you never know when, you know, a well-meaning person bringing up flowers, it could happen. Hopefully, see a couple of you still put in your responses. I'll give you just another second here. Okay. I'm gonna go ahead and end this and share those results. Possibly. Okay, good. I like that there is a variety that you're thinking about this. That's the key to some of my questions. You're thinking about these. Could this actually happen? So training, what do we have to include in training? And I always go back to training because CMS really hammers it. You must require the staff who are gonna be taking care of these patients. They have education training. What are the trigger factors behind this? Maybe it's something going on with staff. They're laughing, having a good jolly time, not realizing, does that trigger a patient? What's going on around them? Is there an event, maybe a birthday celebration or an environmental factor that could trigger it? And that can be anything from loud noises outside your hospital to smoke. Maybe there's a fire nearby and it just triggers this patient for whatever reason. You can use your own program for training. You can use an outside vendor. They don't care. But your providers who order them must have that working knowledge of what your hospital policy is. Now, staff education, they do have multiple resources. They list in the guidelines, in the interpretive guidelines. I've listed them here for you. And this talks about non-physical intervention, the least restrictive intervention. All of these, of course, are based on what is that individual assessment for the patient, their medical behavioral, what is their status, what's their condition going on? So there's multiple resources that help the staff recognize these. Just some examples of triggers. Loud noises, as I mentioned. Maybe there's a fighting going on down the hall between a patient and someone else. That could trigger it. Being touched can set off a patient. And people yelling, teased. All of these are just examples. By the way, on de-escalation, they list out here, again, don't endorse it. Just an example. They have triggers on here on what might have set this patient off. And it helps as far as the personal plan that you're gonna develop. But you have to have education on the safe application and use of all types. How do you recognize, how do you respond to not only psychological distress, but physical distress when you are putting that patient or having them in restraint? Again, the positional asphyxia. They'll talk to staff. Can you identify signs that this patient is having trouble breathing? Or maybe psychological distress. They also wanna see your incident reports. Your injury or death. Is there a pattern? Maybe staff wasn't trained, didn't have enough training. Maybe a little revisit on the training to recognize and respond to them. As far as staff education, specific behavioral changes. Maybe there can discontinue. When can I discontinue this restraint? What behavior can I identify in this patient? Other physiological, psychological status while they're there, how's their circulation, first aid and CPR, they spell it out, this must be part of that training. And it includes everybody, whether it's security or the RNs. And if the security is involved in the application, they must have CPR training and document that training competency in their records because they will want to see them. There is training costs, time spent. It is a recommendation. It is not a mandate. They go from 7 to 16 hours on how long, but they must be trained in safe application and removal. You can revise your programs to annually, four hours per year. And then death reporting. This is an area again where they weren't reported. Whether it was because the staff didn't recognize it, maybe the policy wasn't clear on what had to be done. But you must report to CMS. Joint commission is optional. But if you don't forget to do your thorough, credible root cause analysis. That is one of the items. Death, whether it's restraint or whatever, under joint commission, that is considered a sentinel event. Safe medical device act, you may have to report that. If it occurred, say a restraint vest. By the way, a lot of some of the hospitals, I'm not going to say all of them, but some of the hospitals have stopped using that vest because it does pose a safety issue. And it's usually because of misapplication of the vest. Not all of them have stopped because they sometimes need them. But they do see that that is a safety concern. Overall, you must report the death associated with the restraint or seclusion while they're in it or 24 hours after it was removed. But there's a third one. If you know that death occurred one week after the use of restraint or seclusion where it is reasonable to assume that the use or placement contributed either directly or indirectly to that death. What does reasonable assume mean? It means restriction of movements for a long period of time. Chest compression due in CPR because of positional asphyxia or asphyxiation, restriction of breathing resulted in that patient's death. Doesn't matter the type of restraint, but anything that recurs between two and seven days after it was discontinued. The staff has to document in the record the date and time they reported it to CMS. Now, again, when you report it to CMS, the regional office determines if they have to come back in and do an on-site investigation, not the State Department of Health. You report it phone, fax, or electronically, no later than the close of business day on the next business day after you learned of the death. Include patient information, of course, who they are, birth, death, dates, who is he attending, what was their primary diagnosis, cause of death known at the time, and what type of restraint or seclusion did you use. And then the alternative is when you have those soft wrist restraints. These are like folks in ICU. If you didn't use seclusion and it was only the soft wrist restraints, if death occurred while they were in restraints or within 24 hours, you don't report it to the regional office. Document in the medical record you recorded it on your internal log and do that as soon as possible, like within seven days of death. Include the patient name, date of birth, date of death, who was very similar, and the primary diagnosis. CMS won't want to see your log. When I was at one of my facilities, that's the first thing they asked for when they walk in. Let's see your log death for restraints. All right. I'm going to switch over now to restraint and seclusion. I know that's a lot of information from CMS. This is a huge topic for them on patient rights. So joint commission, there are only ten standards under the provision of care, and two apply to hospitals with dean status. Short, that means you can go joint commission. CMS doesn't have to come in. All standards, elements of performance, they pretty much track with what CMS is saying. So I've got the listing there of those, again, provision of care. You only use restraint or seclusion when it's justified and warranted by the behavior. That's those that threaten the health, safety of patients, staff, and visitors. There are five elements of performance. Protect immediate safety, no discipline, that's not why we're doing it, or retaliation. Least restrictive, didn't work. And the least restrictive way to protect safety, and you're going to stop it as soon as possible. We apply them safely. Two elements. You implement safe techniques according to what your policy and procedures are, and modification in the written plan of care. Same thing with CMS, you have to have an individual order. The provider responsible, they have to do this. That's by law and regulation. No PRN orders. The attending must be consulted as soon as possible if they did not order it. Time limits, again, the same. Four to one hour. Provider sees and evaluates the patient every 24 hours. And these, for your nonviolent, non-self-destructive, non-behavioral health, et cetera, that's according to your policy, how long you keep them up. Again, soft restraints. You monitor the patient by trained providers, and their written policy and procedures on the use. Now, they have two elements of performance. One lists out what has to be in the policy, and I've got that on the next slide. And those who order have a working knowledge of that policy. So I've just typed these right out. The policy has to spell out the training requirements for providers and staff. Who can order? Who can discontinue? Circumstances where they are discontinued, and they're discontinued as soon as possible. Who can assess and monitor the patient? Timeframes for doing so. The definitions of restraint and a seclusion. And what constitutes medication as a restraint. Now, if any of you have seen these provisions, the elements of performance, they sometimes have a little note in there. Note one that talks about the definition of restraint and seclusion. So, again, if you want to find some good definitions, you don't want to use CMS, check out joint commissions. Patients evaluated, re-evaluated by someone who is trained, and within one hour. They then consult with the provider as soon as possible and talk about what happened. Why did we need to do this? Why do we need to continue? Can we terminate? And if you're using simultaneously restraint and seclusion, just like with CMS, they are continually monitored. In-person or video and audio in close proximity. Also, your documentation. That in-person evaluation. What is the behavior of that patient? What did you use as intervention? Alternatives, they weren't, you tried them, didn't work. Their condition that warranted the use, how did they respond? Their individual assessment and reassessment and intervals for monitoring. Then, again, provision of care, that what injuries, if any, happened, was there a death associated with the use of them? Orders, notification, consultation. So, again, these pretty much mirror what is in the CMS regs. Likewise, staff have to be trained. That's before participating in the use and also periodically. Education, they have to really have a good training on what are the triggers, what's least restrictive. First aid, CPR. They talk about train the trainers and staff records show training and competency. For reporting deaths, same thing. You report death within 24 hours after removed. One week also within that time frame, if believed, it's associated. Now, here they talk about reporting electronically, a phone, fax, email. If no seclusion and only soft restraints, again, put it in the log and in the patient record that this is what happened. Now, a few notes on de-escalation. It is not required in the provision of care. It is noted, believe it or not, in the human resources chapter for joint commission. And they talk about it as part of the workplace violence prevention program, de-escalation. So, you may want to add that to your toolkit, if that's what you have. Teach your staff about that toolkit. Really helps if you have those violent self-destructive patients. Some state departments of mental health, they require this on your behavioral health units. So, that's just a few notes on de-escalation. As far as we know the methods, no confrontation. Use that calm voice. Actively listen. Say, hey, I get it. I understand this is what you're feeling. What can I do to help? They also have a quick safety. That's exactly what it's called, quick safety. I have it in the appendix for you, by the way, on de-escalation. It came out in 2019. Really haven't changed much, but it can help reduce the use of restraints and several assessment tools. Joint commission notes 40% of restraint-related deaths because they were unattended asphyxiation while they were in restraint. It can be also traumatizing to the staff if they were involved and the patient died. It should really be used as a last resort. Protect the patient or staff. And of course, some of us are boarding behavioral health patients because we don't have a bed for them. We just have to the patient still safe to prevent that inpatient suicide. You may have a separate room or area in your ED for such patients. There is a free guide on how to set one, set something up. It's called the behavioral health design guide. I have it in the appendix. The most recent one, I think was from 22. I have, there's been no update since then. Self-assessment tool, it's free and you can download it. And then just finally, some final, just some final comments. Include a statement in your patient rights statement. Most of you probably already have it there that they have right to receive care in a safe setting. You have to give a copy of those rights to inpatients and document that they got them. They sign that received it. And maybe if you're still doing admission packets, make sure there's one also in there. Educate everyone, agency included, your contracted people and physicians. They have to be aware of the policy of what are the standards and the state laws. Don't forget the governing body. They have to know what their responsibilities are in this area and leadership. And then make sure staff is trained. They revise your policy and procedures. Look at them at least during your timeframe. Gee, this is outdated. Why are we still using that type of restraint when this is a better one? And audit. Make sure they're doing them correctly. Which brings me to my final one. We have a good 20 minutes, I believe. So I'll go ahead and read this and then have Lindsay put it up. We have a patient who comes to the ED for behavior health evaluation. She has paranoid episodes, long history of paranoid schizophrenia with psychotic episodes. She is managed with therapy at home and medications, but she stopped taking her meds 10 days prior to the submission. Right now, she was brought in because the mom woke up at 1 a.m. to find the patient standing over her with a very large knife, threatening to stab her. She was able to stop the knife and get it away from the patient. Well, on admission, our patient's quiet. She's cooperative. And she gives her name as Madam Z. She doesn't exhibit or voice any suicidal ideation. She still has auditory hallucinations. And they're telling her, defend yourself. Defend yourself. They're going to hurt you. Defend yourself. She consents to blood work, which is completed after they do the MEC. And, excuse me, screening exam. Well, she consents to admission to the inpatient unit. 30 minutes after admission, very agitated. She's scratching herself. And it says, I want out of here. You can't keep me here. I want to go. Let me out. So what can the hospital or should they do? A medicator, physically restrain her, review the assessment, allow any medical reason, anything else you can suggest for our patient. And so I'll have, thank you, Lindsay, put that up, and then see if there's any additional questions. We do have a couple of questions. This first one asks, what is the recommended cadence of ongoing training for triggers, environmental factors, de-escalation, et cetera? One thing you might want to look at, how often are you getting these patients in? Are you a dedicated behavioral health unit? Usually you have staff assigned to those units who know what they're doing. I did float nursing for years. And one of the hospitals did have a behavioral health unit. But there's no way I was able to go into that unit. I could change beds. I could do that stuff. But actually taking care, interacting with patients, no, no. But you put me in a coronary care unit, I'm good. So look at what type of patients and what is the overall competency of your staff? Where are you located? Where are these folks located? Cadence, maybe for those who are well-trained, once a year is enough. For those, you're a new unit or maybe a new staff member, maybe after four months or six months, go back and revisit again. See how they're doing. When you're new, you're assimilating a lot of information just for the hospital alone, let alone trying to take care of patients. So maybe it's good to go back and check with them again to see how often they're doing it. Again, CMS won't say, but at least annually. Make sure each staff member has that revisit at least annually during their skills lab is a good way to do it. Okay. And then this last question I see asked, are there any regulations that state that an RN cannot enter a restraint order if they receive the verbal order from a physician? Yeah, I haven't seen any restraint. No pun intended. I haven't seen any restriction on that one where verbal orders for restraints cannot be taken. Your policy needs to really spell out. Okay. That's great because it's two in the morning. They call the physician, say, yeah, put them in restraint. Physician doesn't have to come in and write the order. Just make sure it's clear in there how soon that ordering physician signs off on that order. The next morning is ideal. So I am not aware of any restriction on that. You might want to check your state law. They may be more restrictive and that's what will rule. State law would override the CMS limitation or anything, silence on it. Right. Okay. We'll go ahead and end this and share the results of the discussion question. Yeah, definitely check out her assessment. What did we miss? Did she slip something to herself while she was home? Just to kind of help quiet down, maybe I'll get to go home early if I take my meds. As far as any other, I don't know if they're in the comment section, what else could they do for her? I like that nobody identified physically restrain her. She was in a crisis. She was in a psychological crisis when she came in and now she's in this locked unit where she couldn't leave and she felt trapped. So yeah, we definitely had to assess her and then start to bring her down with medication. It took a while for her to really settle down and get back on it. And then she did recognize the need to continue her medications. There were some side effects that she didn't like that she felt put her in a fog. And so they were able to modify her meds. Eventually she went home and started to really improve and become an active member within her care. But boy, that's a scary situation for her. So with that, Lindsay, thank you for helping. I do have a few pages of resources, like 17 of them. I'm not going to go through all 17. But as far as talking about the restraint form, that is one, how to fill it out. They actually give us some information on how to do that. And then just some resources. Again, I don't endorse any of them. It's just there for your own information and edification. Again, that's 17, so I won't flip through all of them. So with that, I'll turn it back to you, Lindsay, and see if you have anything else you want to add. Perfect. Thank you so much. And I did just see one final question coming here that goes back to the training question and to see if your answer would be similar. This asks, how often then should staff receive continuing education or training on therapeutic holds? I'd say annually. CMS won't spell it out. They won't. You just have to be able to show staff was trained and they're competent to do it. And annual is a good way to do it. Make sure they're doing it right. Perfect. Okay. And I'm going to go ahead and post some additional information there for you on the chat. Now, I do see a question that just came in asking if there's another way to obtain a copy of the slides. If you, for some reason, are not able to open the Bitly link that I have, I know some hospitals prevent you from opening Bitly links, so that could be the problem. Let's see, Lance, who asked that question. If you are unable to open it through that link, and you would like the slides, you can send an email to education at gha.org and I'll be happy to send you over a PDF copy as an attachment to the email so that you can have access to those slides. But I did go ahead and just provide that link there for you all in the chat as well. And then just a final note that you will receive an email tomorrow morning, but just note that it does come from educationnoreplyatzoom.us. And so because it comes from that Zoom email, those emails do seem to very often get caught in your spam, quarantine, junk folders, the like. So if you don't see that in your inbox in the morning and you'd like to go back and access the recording, you can do so by using the same Zoom link that you used to join us for the live presentation today to also access that recording. You will just need to click on that Zoom link and it'll prompt you to enter your information and that will send an email to us to approve your recording access request. We do approve those very quickly, but we ask that you give us one business day to grant those approvals. And then you will receive a confirmation email from Zoom giving you final access into the recording. And then just remember that the link to the recording is available for 60 days from today's date. And then also included in that email tomorrow morning will be a link to the slides. But again, I did go ahead and provide that there for you in the chat. And if you are joining us as a member of the Georgia Hospital Association, please also pay special attention to the link to the survey that will be in that email tomorrow morning. And that is how you will obtain continuing education credit information. If you're joining us as a member of a partner state hospital association, I encourage you to reach out to your contact within your state hospital association to obtain any further information regarding continuing education credit that your state may have offered for today's session. And yes, Don, I see your question here. I will post the email there for you all in the chat. Again, it's education at gha.org. And that applies if you have just any general questions, you can always send us an email to that email address. Or if you have questions that you'd like for us to pass along to Laura related to today's material, we're happy to do so as well. And then you do see her content information here on the screen. She is wonderful and goes above and beyond always in her responses to questions and we just appreciate her for doing so. Okay, it looks like we have about 10 minutes or so left in our allotted time for today. So we're happy to go ahead and give you that back for your morning. We appreciate you all joining us today. And as always, thank you for your questions and your engagement with us. And Laura, thank you so much for being here with us. And for sharing your time and information. We look forward to having you all back with us for future sessions. And I hope you have a wonderful afternoon. Thank you, Laura. Thank you, everyone. Thank you, Lindsay. Bye-bye.

restraints

seclusion

healthcare settings

patient safety

least restrictive option

assessment process

alternative interventions

monitoring

policies and procedures

documentation

regulations compliance

staff training

licensed practitioners

protocols