CMS SOM App. A, Tag A-0165

intervention that will be effective to protect the patient, a staff member, or others from harm.

Interpretive Guidelines §482.13(e)(3)

Resources are available to assist clinicians in identifying less restrictive restraint or seclusion

interventions. For example, the American Psychiatric Association (APA), American Psychiatric Nurses

Association (APNA), and the National Association of Psychiatric Health Systems (NAPHS), with

support from the American Hospital Association (AHA), have sponsored the publication of a document

entitled, “Learning from Each Other—Success Stories and Ideas for Reducing Restraint/Seclusion in

Behavioral Health.” This document, published in 2003, was developed through dialogue with the field

and extensive input from behavioral healthcare providers throughout the country who have been

working to reduce the use of restraint and seclusion and to improve care within their facilities. To

access this document and other useful resources, visit the web sites of the sponsoring organizations:

http://www.naphs.org; http://www.psych.org; http://www.apna.org; http://www.aha.org

Survey Procedures §482.13(e)(3)

• Is there clear documentation in the patient’s medical record describing the steps or interventions

used prior to the use of the needed restraint or seclusion? That is, what documentation is in the

medical record to explain the rationale for the use of restraint or seclusion?

• Is there documentation that less restrictive measures were tried or considered?

• Is the restraint or seclusion intervention the least restrictive intervention that meets the patient’s

clinical needs and protects the safety of the patient, staff, or others?

• Did the staff determine that less restrictive alternatives would not meet the patient’s clinical

needs, or protect the patient’s safety or the safety of others?

• Do ongoing documented assessments demonstrate that the restraint or seclusion intervention is

needed at this time (or at a time in the past) and that the restraint or seclusion intervention

remains the least restrictive way to protect the patient’s safety?

• If the time of restraint or seclusion use is lengthy, look for evidence that the symptoms

necessitating the use of restraint or seclusion have persisted. Is there evidence to indicate that

the staff have evaluated whether or not the restraint or seclusion can be safely discontinued?