CMS SOM App. A, Tag A-0169

order or on an as needed basis (PRN).

Interpretive Guidelines §482.13(e)(6)

This regulation prohibits the use of standing or PRN (Latin abbreviation for pro re nata - as needed; as

circumstances require) orders for the use of restraint or seclusion. The ongoing authorization of restraint

or seclusion is not permitted. Each episode of restraint or seclusion must be initiated in accordance with

the order of a physician or other LIP. If a patient was recently released from restraint or seclusion, and

exhibits behavior that can only be handled through the reapplication of restraint or seclusion, a new

order would be required. Staff cannot discontinue a restraint or seclusion intervention, and then re-start

it under the same order. This would constitute a PRN order. A “trial release” constitutes a PRN use of

restraint or seclusion, and, therefore, is not permitted by this regulation.

When a staff member ends an ordered restraint or seclusion intervention, the staff member has no

authority to reinstitute the intervention without a new order. For example, a patient is released from

restraint or seclusion based on the staff’s assessment of the patient’s condition. If this patient later

exhibits behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others

that can only be handled through the use of restraint or seclusion, a new order would be required.

NOTE: A temporary, directly-supervised release, however, that occurs for the purpose of caring for a

patient's needs (e.g., toileting, feeding, or range of motion exercises) is not considered a

discontinuation of the restraint or seclusion intervention. As long as the patient remains

under direct staff supervision, the restraint is not considered to be discontinued because the

staff member is present and is serving the same purpose as the restraint or seclusion.

The use of PRN orders for drugs or medications is only prohibited when a drug or medication is being

used as a restraint. A drug or medication is deemed to be a restraint only if it is not a standard treatment

or dosage for the patient’s condition, and the drug or medication is a restriction to manage the patient’s

behavior or restricts the patient’s freedom of movement Using a drug to restrain the patient for staff

convenience is expressly prohibited.

EXCEPTIONS

• Geri chair. If a patient requires the use of a Geri chair with the tray locked in place in order for

the patient to safely be out of bed, a standing or PRN order is permitted. Given that a patient

may be out of bed in a Geri chair several times a day, it is not necessary to obtain a new order

each time.

• Raised side rails. If a patient's status requires that all bedrails be raised (restraint) while the

patient is in bed, a standing or PRN order is permitted. It is not necessary to obtain a new order

each time the patient is returned to bed after being out of bed.

• Repetitive self-mutilating behavior. If a patient is diagnosed with a chronic medical or

psychiatric condition, such as Lesch-Nyham Syndrome, and the patient engages in repetitive

self-mutilating behavior, a standing or PRN order for restraint to be applied in accordance with

specific parameters established in the treatment plan would be permitted. Since the use of

restraints to prevent self-injury is needed for these types of rare, severe, medical and psychiatric

conditions, the specific requirements (1-hour face-to-face evaluation, time-limited orders, and

evaluation every 24 hours before renewal of the order) for the management of violent or self-destructive behavior do not apply.

Survey Procedures §482.13(e)(6)

Review a random sample of medical records for patients that have been restrained or secluded. Review

orders, progress notes, flow sheets, and nursing notes to:

• Verify that there is a physician or other LIP order for each episode of restraint or seclusion;

• Evaluate patterns of use and verify that orders were obtained when necessary;

• Verify that the documentation specifically addresses the patients’ behaviors or symptoms; and,

• Determine if restraint or seclusion is being improperly implemented on a PRN basis.