CMS Restraint and Seclusion: Navigating the Most Problematic of All the CMS Hospital Standards and Proposed Changes

Event Information
Product Format
Prerecorded Event
Sue Dill Calloway, RN, MSN, JD
90 minutes
Product Description

CMS Hospital Standards and Proposed Changes on Restraint and Seclusion

Do you know that the number one area of deficiencies in the CMS CoP is regarding restraints? CMS issued a memo summarizing all of the deficiencies against hospitals which is updated quarterly.

This program by expert speaker Sue Dill Calloway, RN, MSN, JD, will discuss the most problematic standards in the restraint section. This program also discusses the proposed changes to restraint published in the Hospital Improvement Act. This will help you assess your preparedness if a CMS surveyor shows up at your hospital tomorrow, and enhance your staff’s understanding of all of the 50 pages of the CMS interpretive guidelines.

This session will also discuss the requirements for an internal log and what must be in the log for patients who die in one or two soft wrist restraints. Additionally, it will include what must be documented in the medical record and discuss the reporting requirements for patients who die in restraints and within 24 hours of being in a restraint.

Session Highlights

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

Session Outline

  • Right to be free from restraint
  • Number of deficiencies
  • Providing copy of right to patients
  • Restraint protocols
  • Proposed changes in the hospital improvement act
    • PA to order and change from LIP to LP
  • CMS deficiency reports
  • CMS changes effective to internal log and soft wrist restraints
  • Most current manual
  • Medical restraints
  • Behavioral health restraints
  • Violent and self destructive behavior
  • Definition of restraint and seclusion
  • Manual holds of patients
  • Leadership responsibilities
  • Two soft wrist restraints, internal log and documentation
  • Culture of safety
  • Drugs used as a restraint
  • Standard treatment
  • Learning from each other
  • Restraints does not include
    • Side rails, forensic restraints, freedom splints, immobilizers
  • Assessment
  • Need order ASAP
  • Order from LIP and notification of attending physician ASAP
  • Documentation requirements
  • Least restrictive requirements
  • Alternatives
  • RNs and One hour face to face assessment
  • Training for RN doing one hour face to face assessment
  • New training requirements
  • New death reporting requirements
  • Ending at earliest time
  • Revisions to the plan of care
  • PI requirements
  • Time limited orders
  • Renewing orders
  • Staff education
  • First aid training requirement
  • Stricter state laws
  • Monitoring of patient in R/S
  • Joint Commission Hospital Restraint standards and differences from CMS

Who should attend

All nurses with direct patient care, compliance officer, chief nursing officer,  chief of medical staff,  COO, Nurse Educator,  ED nurses, ED physicians,  Medical staff coordinator, risk manager, patient safety officer, senior leadership, hospital legal counsel, Risk Manager, Chief Risk Officer, PI director, Joint Commission coordinator, nurse managers, quality director, chief medical officer, security guards, compliance officer, chief risk officer, accreditation and regulation staff and others responsible for compliance with hospital regulations and anyone involved in the restraint or seclusion of patients. Persons responsible for rewriting the hospital policies and medical staff bylaws should attend. This also includes staff who remove and apply them as part of their care such as radiology techs, ultra sound technologists, transport staff, and others.

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About Our Speaker

Sue Dill Calloway - Hospital Coding Expert

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the...   More Info
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