Restraint and Seclusion: Navigating CMS Standards and Proposed Changes — Virtual Event

Audience

chief medical officers, chief nursing officers, compliance officers, emergency department personnel, TJC coordinators, medical records and quality improvement personnel, risk managers, and legal counsel

The following program content was provided by the speaker.

Overview

Restraint and seclusion is a hot topic with both the Centers for Medicare & Medicaid Services and The Joint Commission as it is a common area where hospitals are cited for being out of compliance. Restraints are the number one area of deficiencies for a specific requirement in the CMS Conditions of Participation. This program will discuss the most problematic standards in the restraint section.

Any physician or provider who orders restraint must be trained in the hospital’s policy. Both CMS and TJC require hospital staff to be educated on restraint and seclusion interpretive guidelines annually. CMS also says that restraint training must be ongoing, so the training should be provided beyond orientation.

CMS has 50 pages of interpretive guidelines on restraint and seclusions for hospitals. Every hospital that accepts Medicare patients must comply with the interpretive guidelines even if the hospital is accredited by TJC, HFAP, CIHQ or DNV Healthcare. This program provides a crosswalk to TJC standards.

Objectives

Upon completion of this program, participants will be able to:

• define the CMS restraint requirement of what a hospital must document in the internal log if a patient dies within 24 hours of wearing two soft wrist restraints
• recall that CMS requires that all physicians and others who order restraints must be educated on the hospital policy
• describe that CMS has restraint education requirements for staff
• discuss that CMS has specific requirements for documentation in the medical record for the one-hour face-to-face evaluation on patients who are violent and or self-destructive

Speaker

Laura A. Dixon, JD, RN, CPHRM, most recently served as the Director of Risk Management and Patient Safety for the Colorado Region of Kaiser Permanente. Before joining Kaiser, she served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Dixon provided patient safety and risk management consultation and training to facilities, practitioners and staff in multiple states.

Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services and pain management. Before joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company in Napa, Calif. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western U.S. As a registered nurse and attorney, Dixon holds a Bachelor of Science from Regis University in Denver; a Doctor of Jurisprudence from Drake University College of Law in Des Moines, Iowa; and a registered nurse diploma from Saint Luke’s School Professional Nursing in Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.

This educational activity is provided by MHA Health Institute in collaboration with the Georgia Hospital Association.