By Marty Piepoli, MSW, LISW-CP
Not that the changes made to the Conditions of Participation in 2007 regarding restraints were confusing enough, The Joint Commission and CMS continued their dialogue around Deemed Status expectations with the release of several pages of TJC standards in January of this year with subsequent revisions in March. Those standards are now being scored by TJC and are reflected in the organization’s survey report. At C&A, we have received multiple inquiries related to orders, assessment, reassessment, monitoring, documentation, etc. This article will provide answers to some frequently asked questions. Ultimately, sending a question to the Standards Interpretation Group (SIG) and reviewing the CoP’s are the best approach for clarification on organization-specific questions.
In the June edition of The Joint Commission Perspectives, TJC noted that the CoP-related standards (PC.03.05.01-PC.03.05.19) will apply to those organizations that use TJC for deemed status purposes. The other standards covering restraints (PC.03.02.01-PC.03.03.31) were thereby replaced, effective July 1, 2009, and will only apply to organizations that do not use TJC for deemed status purposes. Here are some questions to consider:
Question: Is there a timeframe requirement expected for the length of a restraint order for patients who are restrained for non-violent or non-self-destructive health purposes?
Answer: Orders for restraint used to protect the physical safety of the nonviolent or non–self-destructive patient are renewed in accordance with hospital policy. (PC.03.05.05 EP#6) Organizations would determine the length of time based on patient safety, patient assessment and the type of restraints used. Keep in mind that for restraint or seclusion used for violent or self-destructive behavior requires re-evaluation by an LIP at least every 24 hours before a new order is written.
Question: What are the monitoring requirements for patients in a non-behavioral health restraint?
Answer: Organizations would determine the monitoring time frames for a patient in non-violent, non-self destructive restraints. Again, patient safety, patient assessment and the type of restraint used would determine the monitoring requirements. Each organization should reference PC.03.05.07 EP#1, PC.03.05.09 EP#2, which address training expectations (482.13 (f)) and requires all practitioners who order restraint or seclusion to have a working knowledge of the hospital policy.
Question: What are assessment expectations for patients utilizing restraints for violent/self destructive behaviors?
Answer: Based on patient safety, type of restraint used, organizations should develop policies and procedures that address patient assessment and monitoring requirements. Review TJC PC.03.05.07 thru PC.03.05.13 and the CoP under 482.13 (e)(1)(i)(B)
Question: Is there a requirement for data collection for PI?
Answer: There is no specific standard that addresses data collection for Performance Improvement. Reviewing PC.03.05.03 EP#1 will provide direction related to leadership ensuring that systems and processes have been developed, implemented, and evaluated to support patient rights. PI activities would ensure that these policies and procedures are followed in the use of restraint and seclusion. Additionally, check LD.04.04.01 and LD.04.04.05 as it relates to your organization’s patient safety program.
Question: How is documentation of restraints to be handled?
Answer: Though there is not a specific reference in the RC.02.01.05 for deemed status restraint documentation, organizations should be reviewing RC.01.01.01 EP #6/7, RC. 02.01.01 EP#2 which address a complete and accurate medical record and reference to documentation to how a patient responds to treatment, care, services, plans of care, etc. The CoP Interpretive Guidelines also speak to documentation requirements.
More questions are likely, as scoring begins and the dialogue between TJC and CMS continues regarding the Deemed Status expectations. Stay tuned for updates from C&A as information breaks related to this issue and others that affect the safe delivery of care to the patients we serve.
Sources: TJC Comprehensive Accreditation Manual for Hospitals, July 2009, Conditions of Participation- SOM-A (released 6/5/09) 482.13 e/f/g