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So I was asked, or actually I volunteered, to pick up Section P for this person
who had to leave. So, it was the end of the day. I hadn't really prepped for it,
although I know restraints in this section quite well, and I was a little
punchy. I'm not quite as punchy today as I was then. I had been teaching for a
few days, but I started off April, and I'm going to do the same here.
So, first off, I've been in long-term care for a long time, and, so, as I looked
out and we started talking about restraints, I said, "Does everyone remember
back --" well, first off, who was in long-term care in the '80s? Wow, a lot of
people. All right. I don't feel so old anymore. >> Audience: Laughter >> Ok, I'm
sure there's people who were in even sooner than that, but, really, so, let's
think about the '80s in long-term care in the United States. So, we used
restraints, right? Yeah. What kind of restraints did we use? Poseys. Ok, how
about, like, the crotch restraint? How about the vest restraint? Everyone had a
vest restraint, right, and usually some other type of restraint and, of course,
the tie-waist restraints. How about the Houdinis? Oh, yeah. Okay. How about the
wrist restraints, right? We used to tie people down all the time. The mitts? Big
mitts. Yeah, okay. How about - we put the vest restraint and then we bring them
out in the hallway and tie them to a sheet to their wheelchair. Right? Am I
making this stuff up? No. What else did we do? You tied their sheet to the bed
frame. Yeah? Anyone ever hear of that one? Someone told me about Velcroing. They
had a whole system of velcroing the sheets. I didn't know that one. What else?
Locking wheelchairs. What else did we do? Handrails. >> Audience: Haldol. >>
Haldol. Right. We're not even getting into -- we're talking about physical
restraints. >> Audience: Laughter >> It was like an awakening when we took all
the Haldol away. It was amazing.
We think about it. You went into a nursing home, what did you see? Everyone was
tied up, right? So, were we awful people back then? Were we horrible? No. No, we
did what we knew and what we thought was best at that time. Right, and we've
learned since that time. I can tell you, you know, back in the day, I had one,
like, really creative CNA whose resident, she couldn't find the wrist
restraints. So, she took knee highs and tied the knee highs to the rails. You
know, I mean, I found people, when I was a night supervisor, with the -- you
know -- the vest restraint up around here they're between the side rail and all
but hanging. I mean, it's sad, but that was a fact, right? And trays, how many
people had trays in the Geri Chairs? Right, you know. At least 50 people lined
up, right? I mean, that was what we saw. That's what we knew. All right.
Now, tomorrow -- to divert a little bit, the same thing, late '70s, early '80s
-- early '80s, let's say. People who worked maybe in long-term care and acute
care -- what was, like, the greatest thing we did to treat pressure ulcers?
Maalox and the heat lamps. [Unintelligible] All right for heat lamps. How about
the Maalox? We used to roll the old people over and tape their cheeks to the
side rail. >> Audience: Laughter >> Right? Okay. So, for all you young'ns out
there -- people that were not around for those days, and I know there's folks
that are older than I am or have been in healthcare longer than I have, or
whatever, that can tell other stories, but these are facts. This is what we used
to do.
So, we've learned a lot. It's tremendous. So, everything that we do, we need to
take in and kind of and pace and realize we are making strides as we understand
the devastation and the negative outcomes from putting a restraint and the fact
that people die, even today, or have horrible outcomes because of worsened falls
climbing over side rails, and whatnot, and fractures -- all the things that we
do.
Now, let me go back to one of my questions that I asked. Why did we restrain so
many people? We prevented falls. Why? Because what? We knew best. We were the
parent, right? Kind of parent figure. We did what we thought was best -- we were
the parent towards them. "You can't - honey, you can't do that, so we're just
going to tie you in. You can't fall." "Now you have a pressure ulcer, you're
incontinent and you've got contractures, but you didn't fall." >> Audience:
Laughter >> Right? Okay. So, you know: 'Do no harm.' We did a lot of harm, and
there are people today who still struggle with the idea that we really could, if
we were creative, and we had the resources and the time, truly, I think we
really could be restraint-free. There are states that have done it. There are
homes that have done it. There are corporations or groups of homes that have
done it, and been quite successful and would love to share with you what they've
done. So, I encourage you, if you happen to be one of those facilities who still
has a lot of restraints or is struggling with this, please find someone in your
community in your area who has been successful and meet with them. Go see. What
are they doing differently?
A lot of it comes down to attitude. I mean, I remember being in the nursing
home. I was a director -- and I will actually get to coding in a second -- and I
struggled so hard. I got my day staff and night staff on board. My night staff?
*Click* I mean, all side rails went up. I struggled with restraints. They, night
shift, ultimately, on the weekends would put restraints on people, get orders.
I'd come back on morning and have to get them all DC'ed. I mean, it was a
battle. I put a decree in place in my facility because I believed -- and I had
seen what could happen -- and I said no one in this facility can have a
restraint put on unless you call me. Seven days a week, 24 hours a day. Do you
know how many people wanted to call me at 2:00 a.m. in the morning? >> Audience:
Laughter >> They thought long and hard and creative before they had to call me
at two in the morning. Did I get calls? Yeah I did, but I made it difficult for
them to put a restraint on someone. I made it hard, and we worked through it. It
took time, but then they bought into it and they understood and they started
thinking creatively and being able to be successful. So, change is difficult.
That being said, MDS 3.0 has changed, and how do we all feel about it? We're
scared, right? I'd be scared. We're apprehensive, we're scared. We think it's
going to be more difficult. We don't believe the gold standard nurses. We don't
think it's real; but, I can tell you, I believe in this. I believe that it's a
dynamic process. We will continue to improve it, and that hopefully, it will
really be the tool that it needs to be, even though we serve many masters. As
Terri Mota always says, this tool serves a lot of masters, but we can make this
work for us.
So, related to Section P and restraints, we're going to talk about what
constitutes a physical restraint and for the purposes of the MDS 3.0, and we're
going to explain how to assess a resident for physical restraint, and then how
to code Section P.
So, what we're going to do here is we're going to record the frequency that we
are using the restraint and in what setting. So, it's like an in-bed and
out-of-bed type of setting -- if you've looked at the tool -- and we're going to
evaluate whether or not the device meets the definition of a physical restraint
for the purposes of the MDS 3.0, according to the following three criteria. And
we should probably -- this should be a creed and we should probably all stand
and, like, raise our right hand for this one, because: "If it's any manual
method physical or mechanical device, material or equipment, attached or
adjacent to the resident's body that the individual cannot remove easily, which
restricts the freedom of movement of normal access to one's body." I can bet
that most of you out there could have almost recited that along with me. Right?
Okay. So, what does that mean? What does that mean? So, only the devices that
categorize in Section P0100 that have the effect of restraining the resident
will be coded. It is not the intent. Okay? It's not about the intent. It's the
effect upon the resident.
The use of physical restraints is not prohibited. There's some people who say
it's prohibited. It's not. I just told you my belief, and I think we've learned
that it's not the best thing that we should do, but it's not prohibitive and it
can't be imposed for discipline or convenience. And I know people struggle with
that sometimes. Staff's like, I just -- they're running after someone, they're
running, running, running, running, running, and all of a sudden you realize
that, you know, Sally's not running around the hallway in her wheelchair. When I
say running, I mean literally, in her wheelchair running -- and you look and
Sally's in her room and, you know, she's calling out or whatever and you go in:
What is Sally -- why is she still? Because what did they do to her wheelchair?
They locked it. Have you ever seen the residents -- they're pulling that
wheelchair down the hallway and that one that stands up has the wheelchair on
her back. >> Audience: Laughter. >> Okay? Have you ever seen that? Come on,
guys. I don't make this stuff up. All right, so locking that wheelchair. What do
you think the effect-- I just described two people -- what do you think the
effect of locking the wheelchair for those residents was? Restraint. We don't
think about locking a wheelchair as being a restraint, do we? But in certain
situations, like I just described, because we're trying to keep someone
somewhere for, you know, staff convenience in that particular situation, that
may be considered a restraint. Okay, but we certainly weren't going to be coding
it right here.
"Must assess the resident's needs and medical symptoms before using a physical
restraint, and the use of physical restraints should be the exception not the
rule." Please -- and you know what -- it comes down from leadership, folks. I
mean, you can have a unit where you have a unit manager or supervisor who really
believes in not restraining and will do everything, but unless you have really
good strong leadership -- meaning nursing leadership and administrative
leadership who really sets the picture and the tone -- they're the ones who are
going to drive this and support it in your nursing home. So, it needs to come
from the top.
So, P0100 - the importance. It can play a limited role in medical care. We know
that it limits mobility and, of course, we know the negative outcomes from
restraint. You know even that resident who is a frequent flyer or frequent
faller, as we call them, right? Number one reason why we end up restraining
someone, right, is for falls, and we take that resident - what happens when we
put them even just in a wheelchair? They lose function, don't they, and they
lose it pretty darn quickly. So, we got to keep our people up and moving as long
as possible. So, even not just restraining them but taking them and really
confining them or signing them and putting them in a wheelchair. Again, not
meaning this, we can lose a lot of function, or we cause depressed mood. Can you
imagine if you were able to get up and walk around all the time, and now all of
a sudden you had to be in a wheelchair? That's hard. All right? You have less of
a sense of self, and then, if you had to be tied in, what does it do? People get
agitated with it. So agitation, inevitably, you know -- people will say, "You
know, we need to put this on." Well, the person is so agitated, staff spent half
the time trying to calm the person down to put it on. If you had just got up and
walked them around or maybe put them in an activity or did something else, you
wouldn't have had to use the belt, the lap buddy, whatever it is you had to put
on that particular person.
So, we know that cognitively-impaired residents are at higher risk due to
physical restraints for entrapment, injury and death. I mean that just makes
sense. They can't understand how to go through the process of releasing it for
many of our residents, and then there's significant risk of restraint related
injuries or death. The literature supports this. All you need to do is go ahead
and do a search on this. CMS has published some stuff on restraints. So, in the
physical restraint section, we already talked about this. I just went through
this definition and the definition is written right on the MDS, so you have it
there as reference material. So, "removes easily" can be removed intentionally
by the resident in the same manner that it was applied by the staff. So, it's
not going to be considered a restraint if the resident can take it off. Well, I
can't even tell you how many times I've gone out to facilities, and, you know,
the lap buddy - that's that foam thing that fits in the front of the wheelchair,
okay, and people say to me, "Mary gets it off. She gets it off all the time."
But it's not upon command. Mary fiddles for two and a half hours, and then Mary
gets it off. >> Laughter. >> Guess what? It's a restraint, yes? You know, or
someone fiddling with a belt. If they fiddle enough with it, they get agitated
enough, sometimes they can get it off. It doesn't meet the intent at that point.
You need to be able to go up to someone and say, "Can you remove this for me?"
and if they say, "Oh, yes," they unclick it and do whatever and open it for you
or show you how to do it, all right for that particular person. Just do it on a
regular basis. Put a system or a process in place to make sure it doesn't
transition from something that does not meet the criteria for a restraint to
something that does meet the criteria. If the resident changes it at all and
then consider the resident's physical condition and ability to accomplish his or
her objective for what they need to do. And then freedom of movement: "any
change in place or position for the body, or any part of the body that the
person is physically able to control or have access to." So, that's when we talk
the freedom of movement. So, if someone wants to scratch their knee, they can.
You know, if we have a tray and they can get to that knee or if they want to
cross their legs or they want to do whatever they want to do, they need to have
freedom of access to their body. Otherwise, it potentially - the effect upon the
resident is that it could be a restraint.
We have lots of different types of restraints and there's a bunch listed here.
They could be facility practices. Again, Velcro on sheets - that's another one
that's on here. I've never seen that, but I guess if it made it to the list
here, it must be happening somewhere in the United States. You know, I always
say to staff: taking someone and locking their chair and putting them up against
a wall or up against a table and they can't move, the effect could be the same
thing -- putting them in a chair, getting them in an area they couldn't get up
and move. So, we want to make sure when we're coding this particular item, we're
going to look at the medical record. We're going to talk to all the staff across
all the shifts. We want to make sure we know what's going on with this
particular resident - [that] something isn't going on at night that we aren't
aware of. Okay? So, you want to make sure you're talking to the staff. Observe
the resident to determine the effect of the resident's normal function, and do
not focus on the type or the intent or the reason for the use. It's the effect
upon the resident.
So, when you teach this, that's the key because people want to say, "But, Ann,
if they didn't have that, they couldn't get out of their rooms, and they
couldn't go to activities," and whatnot. I'm not arguing with you. That's great.
I'm not saying that it's not the best thing for this particular resident, and
I'm not telling you can't do it, but I'm telling you to code the MDS. What is
the effect of whatever you're applying or doing to that resident's ability to
have free access to their body and to move around and then make your evaluation
from that point forward? Do not focus -- we just talked about this. Focus only
on the effect of the device on the resident. We've now said that about three
different ways in four different slides here. So, hopefully you've gotten the
message there, and assess each resident individually.
So, this is the other thing. I wrote a note to myself that I wanted to make sure
that I covered here, that we want to make sure -- people have come up to me and
there's a couple of words I want you to stay away from with restraints. "Always"
and "never". So, the word "always" and the word "never". Remember that as
related to restraints. So, people - so, I just finished teaching this at the
April conference, and people came up to the side and were asking me some
questions. They said, "Well, you know a consultant came in and they said XY --
We never should code a restraint if it's XYZ." Or, "We always code lipped
mattresses as restraints." You know those concave mattresses? Okay, what do you
think of that? You have to look at each. What's the effect upon the resident? It
depends. So, it's never an "always" or never a "never". So, as soon as someone
spits that out of their mouth, stop them. Say, "Stop. Can't think that way."
There's no blanket -- everyone wants a blanket. They want a widget. They want to
put it in a hole. They want this to become -- they want it to be black and
white. And guess what? This section, along with other sections in the MDS, is
not black and white. It's gray and various shades of gray. So, you have to look
at the particular resident. So, one device may be a restraint for me and may not
be a restraint for someone else. So, we have to look at it that way, and until
you get your staff thinking that way, you're going to really struggle with this
particular item. That doesn't mean, internally, that a facility can't say every
time we apply a device, we go through a standard operating procedure. We talk to
the family. We talk to the resident, we do all these assessments, we care plan
it, we actually put it as a physician order, we care plan for very close
observation, and whatever. So, even then, they're not going to code on it the
MDS as a restraint. They still have an internal process that has all the other
mechanisms in place. That's fine, but what we're looking at here is how do we
code the MDS for an item. So, remember the "never" and "always".
So, the device must meet the full definition. So, they need to have a physician
documentation, the medical symptom that supports the use of the restraint, and I
find that often missing: what is the medical symptom that we're treating here.
And physician order of the type of physical restraint and the parameters in of
use: when are you going to use it, when is it going to be on, when is it going
to be off and then care plan and a process in place for systematic and gradual
physical restraint reduction and elimination. I think we've done a better job in
the United States. I mean, we think, literally, now we can say the positives,
where we were in the '80s and where we are now, 2010, related to restraints,
even if you look into the latter part of the '90s. So, in the last 10 to 12
years, huge improvement. I think we're getting there, but we need to continue
down this road.
So, what we're going to be looking to code here is how often the physical
restraint was used, the location of the physical restraint - and what we mean
here is the two places: in bed or in the chair or out of the bed. So, what
happens when they're in the bed and what happens when they're out of the bed or
in a chair? And then the category of restraints are bed rails, or chairs to
prevent rising, trunk, or limb restraints, and we're going to code all physical
restraints used during that seven day look back period. So, when you look at the
MDS items here, you have the coding methodology on as you're looking at this,
your left. You wouldn't want me doing surgery on your right. I'd be the surgeon
doing this: [Looks around, pretending to be confused]. So, on your left here,
the coding: so, was it not used, used less than daily or used daily? That's
pretty simple. And then we want to say - enter the code in the boxes. So, did
they use bed rails? Yes, my head -- they're using bed rails and for this
particular resident it meets the criteria of constraints, because it's not every
bed rail we're coding here. Right? So, we've done all the assessments. We've
determined that this particular resident's side rails meets the restraint
definition, and we use them daily. So, you would put a "2" in the "A", saying we
used the bed rails. And, then, trunk restraints, limb restraints and then
others, and then under chairs and out of bed, we have chairs to prevent rising
and then we have "other". So, items that are not specifically listed here, but
meet the criteria for restraint, would be coded under "other" and then we would
expect all of those other components to be in place, right? The physician order,
the care planning, treating the medical symptom - even though we're not saying
what that "other" is here.
So -- and then we talked about this already -- and "other" means any device that
does not fit the list and it meets the criteria. It should be care planned and
monitored. We talked about that. Okay. So where are we time-wise? We have, like,
five minutes, right? I think it ended at 4:30. My section? Okay, so we've got a
lot of time.
Okay, so, what's the intent of Section P? Answer my questions here. What do you
guys think? So, we'll do a little quiz. I don't have prizes like Tom did,
though. Sorry. I should have brought candy, right? We could have thrown candy
out to people. It would have been good. So, what would you say here? Is it A: to
identify any device, material or equipment that serves to restrain the resident
in any way? Is it B: to document the number of devices that are used to restrain
the resident at any time during the look-back period; C: to record the frequency
the resident was restrained by the list of device at any time over the look back
period; or D: specify the type of restraint that was used on the resident to
meet the medical requirements. >> Audience: C. >>
>> Okay. Which of the following does not meet the criteria for coding of a
physical restraint? A: a manual method or physical or a mechanical device
material or equipment; B: used for the purpose other than to treat medical
symptoms or improve the patient mobility; and C: attached or adjacent to the
resident's body that the individual can't remove; and D: restricts the freedom
of movement or normal access to the body? >> Audience: A. >>
>> Okay, so B. It's used for the purpose other than to treat medical. So, what
it's saying, what is -- really, it's how the question is written. What are all
the criteria that meet, kind of, physical restraint? So, the one that doesn't
fit into the whole group there is B. Right? Because it has to meet -- it has to
treat a medical symptom. Right? That's part of the definition. That's a little
bit of a tricky question.
Alright. So, when determining if a device, material or equipment meets the
definition of a physical restraint, what is the key factor to consider? You
should all know this question. >> Audience: D. >> You're going to hear it in
your sleep. "What's the effect of restraints?" You're probably sick of me saying
it. "D". "What's the effect upon the resident?" That's really the key here.
You must code all devices you identify that meet the definition of a restraint
for the purpose of the MDS. >> Audience: True. >> Right. Okay.
If a device or material equipment meets definition of physical restraint, but
increases mobility for the resident, do not code as restraint >> Audience:
False. >> Right, good. It's okay. We still code it as a restraint, but we take
credit for it then.
The codes you select for a physical restraint indicates what? So, what does it
do? A: the frequency with which the restraint was used or observed during the
look-back period; the type of restraint used during the look-back period; or how
the restraint was used to limit resident's mobility during the look-back period?
>> Audience: C. >> Well, it's actually "A" because it's a frequency code. How
often are we using it? You know, we're using it not daily, daily or not at all.
Alright, it's, again, a little bit of a quirky question depending how you read
it. It's also telling you what restraint you used, right, because you're coding
the type of restraint. I can see -- so it's okay. So, first we're going to
identify which one of the restraints and then we're putting up frequency. So,
all right I'm the Proctor. We'll take that question out. We won't count that on
the test. Alright.
So, really these are all -- I'm not going to read these slides or anything.
These are the same things that we talked about. So, the biggest thing - the
take-home message - is we have to be champions of restraints. This is passion.
This is a huge issue for quality of life for our residents. We have to fight
families sometimes on this. We can't restrain just because a family wants us to
restrain. We have to go through this whole process, and it takes a lot of time
and effort to make sure that we explain to our residents and to our families
that by putting a restraint on someone does not guarantee that they won't fall,
right, and they won't get hurt. But, if they do fall and they're restrained or
they do fall they have side rails up, what's the negative of it? They have a
much greater chance of having a major injury, right? So, maybe they would have
fallen and, you know, had a bruise but now we've added side rail or now they've
climbed six or seven inches over that now, and we go to the floor and have a
fracture.
So, are we [unintelligible] - yeah. I'm done. So, thank you very much.
[stop here]