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When the interdisciplinary team determines that the use of physical restraints is the appropriate course of action, and there is a signed physician order that gives the medical symptom supporting the use of the restraint, the least restrictive manual method or physical or mechanical device, material or equipment that will meet the resident’s needs must be selected. Care planning must focus on preventing the adverse effects of physical restraint use.
Steps for Assessment
Review the resident’s medical record (e.g., physician orders, nurses’ notes, nursing assistant documentation) to determine if physical restraints were used during the 7-day look-back period.
Consult the nursing staff to determine the resident’s cognitive and physical status/limitations.
Considering the physical restraint definition as well as the clarifications listed below, observe the resident to determine the effect the restraint has on the resident’s normal function. Do not focus on the type, intent, or reason behind its use.
Evaluate whether the resident can easily and voluntarily remove any manual method or physical or mechanical device, material, or equipment attached or adjacent to his or her body.

If the resident cannot easily and voluntarily do this, continue with the assessment to determine whether or not the manual method or physical or mechanical device, material or equipment restricts freedom of movement or restricts the resident’s access to his or her own body.
Any manual method or physical or mechanical device, material or equipment should be classified as a restraint only when it meets the criteria of the physical restraint definition. This can only be determined on a case-by-case basis by individually assessing each and every manual method or physical or mechanical device, material or equipment (whether or not it is listed specifically on the MDS) attached or adjacent to the resident’s body, and the effect it has on the resident.
Determine if the manual method or physical or mechanical device, material, or equipment meets the definition of a physical restraint as clarified below. Remember, the decision about coding any manual method or physical or mechanical device, material, equipment as a restraint depends on the effect it has on the resident.
Any manual method or physical or mechanical device, material, or equipment that meets the definition of a physical restraint must have:
• physician documentation of a medical symptom that supports the use of the restraint,
• a physician’s order for the type of restraint and parameters of use, and
• a care plan and a process in place for systematic and gradual restraint reduction as appropriate.

The identification of medical symptoms should assist the nursing home in determining if the specific medical symptom can be improved or addressed by using other, less restrictive interventions. The nursing home should perform all due diligence and document this process to ensure that they have exhausted alternative treatments and less restrictive measures before a physical restraint is employed to treat the medical symptom, protect the resident’s safety, help the resident attain or maintain his or her highest level of physical or psychological well-being and support the resident’s goals, wishes, independence, and self-direction.
Physical restraints as an intervention do not treat the underlying causes of medical symptoms. Therefore, as with other interventions, physical restraints should not be used without also seeking to identify and address the physical or psychological condition causing the medical symptom.
Physical restraints may be used, if warranted, as a temporary symptomatic intervention while the actual cause of the medical symptom is being evaluated and managed. Additionally, physical restraints may be used as a symptomatic intervention when they are immediately necessary to prevent a resident from injuring himself/herself or others and/or to prevent the resident from interfering with life-sustaining treatment when no other less restrictive or less risky interventions exist.
Therefore, a clear link must exist between physical restraint use and how it benefits the resident by addressing the specific medical symptom. If it is determined, after thorough evaluation and attempts at using alternative treatments and less restrictive methods, that a physical restraint must still be employed, the medical symptoms that support the use of the restraint must be documented in the resident’s medical record, ongoing assessments, and care plans. There also must be a physician’s order reflecting the use of the physical restraint and the specific medical symptom being treated by its use. The physician’s order alone is not sufficient to employ the use of a physical restraint. CMS will hold the nursing home ultimately accountable for the appropriateness of that determination.

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