Restraint and Seclusion: Navigating a Problematic CMS Standard

The topic of restraints and seclusion is hot for CMS and accreditation agencies and is an area of high risk for hospital non-compliance. Solid policies, procedures, and processes are required for success with the use of restraints or seclusion. One of the most cited areas of deficiencies for CMS Conditions of Participation (CoP) is restraints and seclusion. 

This training will cover the requirements for restraints and seclusion per CMS standards. The information provided will inform and help address potential gaps that could be areas of deficiency during CMS or accreditation surveys. 

After completing this program, the participant will be able to:

• Identify the importance of CoP compliance in a hospital setting 
• Examine CMS requirements for use of restraints and seclusion
• Describe the components that are required by CMS for provider orders of restraints and 
• Discuss the education requirements for restraints and seclusion
• Review the CMS documentation requirements for restraints and seclusion 
• Describe the areas of risk and commonly cited deficiencies within the CoP standards for restraints and seclusion

• Introduction to CMS CoPs
• Overview of patient rights related to restraints and seclusion
• What are restraints and seclusion
• Order requirements for restraints and seclusion
• Assessment needs for restraints and seclusion
• Education and training required for restraints and seclusion
• Documentation requirements for restraints and seclusion
• Areas of risk and commonly cited deficiencies

• All Nurses with direct patient care
• Compliance officer, Chief Nursing Officer
• Chief of Medical Staff, COO
• Nurse Educators, ED nurses, ED physicians
• Medical Staff Coordinator
• Risk Manager, Patient Safety Officer
• Senior leadership, Hospital Legal Counsel
• Chief Risk Officer, PI Director
• Joint Commission Coordinator
• Nurse Managers, Quality Director
• Accreditation and Regulation Staff and others responsible for compliance with Hospital Regulations
• Anyone who may be involved with patients who have restraint or Seclusion of patients.
• Persons are responsible for rewriting the hospital policies and Medical Staff bylaws.
• Staff that removes and applies them as part of their care such as Radiology techs, Ultrasound technologists, Transport staff, and others.