CMS SOM App. A, Tag A-0175

physician, other licensed practitioner or trained staff that have completed the training criteria

specified in paragraph (f) of this section at an interval determined by hospital policy.

Interpretive Guidelines §482.13(e)(10)

Ongoing assessment and monitoring of the patient's condition by a physician, other LP or trained staff is

crucial for prevention of patient injury or death, as well as ensuring that the use of restraint or seclusion

is discontinued at the earliest possible time. Hospital policies are expected to guide staff in determining

appropriate intervals for assessment and monitoring based on the individual needs of the patient, the

patient's condition, and the type of restraint or seclusion used. The selection of an intervention and

determination of the necessary frequency of assessment and monitoring should be individualized, taking

into consideration variables such as the patient’s condition, cognitive status, risks associated with the use

of the chosen intervention, and other relevant factors. In some cases, checks every 15 minutes or vital

signs taken every 2 hours may not be sufficient to ensure the patient’s safety. In others, it may be

excessive or disruptive to patient care (e.g., it may be unnecessary to mandate that a patient with wrist

restraints, and who is asleep, be checked every 15 minutes and awakened every 2 hours to take the

patient’s vital signs). Similarly, depending on the patient’s needs and situational factors, the use of

restraint or seclusion may require either periodic (e.g., every 15 minutes, every 30 minutes, etc.) or

continual (i.e., moment to moment) monitoring and assessment.

Hospital policies should address: frequencies of monitoring and assessment; assessment content (e.g.,

vital signs, circulation, hydration needs, elimination needs, level of distress and agitation, mental status,

cognitive functioning, skin integrity, etc.); providing for nutritional needs, range of motion exercises,

and elimination needs; and mental status and neurological evaluations.

With the exception of the simultaneous use of restraint and seclusion, one-to-one observation with a

staff member in constant attendance is not required by this regulation unless deemed necessary based on

a practitioner’s clinical judgment. For example, placing staff at the bedside of a patient with wrist

restraints may be unnecessary. However, for a more restrictive or risky intervention and/or a patient

who is suicidal, self injurious, or combative, staff may determine that continual face-to-face monitoring

is needed. The hospital is responsible for providing the level of monitoring and frequency of

reassessment that will protect the patient's safety.

Hospitals have flexibility in determining which staff performs the patient assessment and monitoring.

This determination must be in accordance with the practitioner’s scope of clinical practice and State law.

For example, assessment and monitoring are activities within a registered nurse’s scope of practice.

However, some trained, unlicensed staff may perform components of monitoring (e.g., checking the

patient's vital signs, hydration and circulation; the patient’s level of distress and agitation; or skin

integrity), and may also provide for general care needs (e.g., eating, hydration, toileting, and range of

motion exercises). Section 482.13(f) requires that before applying restraints, implementing seclusion, or

performing associated monitoring and care tasks, staff must be trained and able to demonstrate

competency in the performance of these actions.

Survey Procedures §482.13(e)(10)

• Review hospital policies regarding assessment and monitoring of a patient in restraint or

seclusion.

o What evidence do you find that the hospital’s monitoring policies are put into practice for all

restrained or secluded patients?

o Do hospital policies identify which categories of staff are responsible for assessing and

monitoring the patient?

o Do hospital policies include time frames for offering fluids and nourishment,

toileting/elimination, range of motion, exercise of limbs and systematic release of restrained

limbs? Is this documented in the patient’s medical record?

• Review patient medical records:

o Was there a valid rationale for the decision regarding the frequency of patient assessment and

monitoring documented in the medical record?

o Was documentation consistent, relevant, and reflective of the patient’s condition?

o Are time frames described for how often a patient is monitored for vital signs, respiratory and

cardiac status, and skin integrity checks?

o Is there documentation of ongoing patient monitoring and assessment (e.g., skin integrity,

circulation, respiration, intake and output, hygiene, injury, etc)?

o Is the patient’s mental status assessed? Is this documented in the medical record?

o Is the patient assessed regarding continued need for the use of seclusion or restraint?

o Is there adequate justification for continued use and is this documented?

o Is the level of supervision appropriate to meet the safety needs of the patient who is at a

higher risk for injury (e.g., self-injurious, suicidal)?

A-00176

(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

§482.13(e)(11) - Physician and other licensed practitioner training requirements must be specified

in hospital policy. At a minimum, physicians and other licensed practitioners authorized to order

restraint or seclusion by hospital policy in accordance with State law must have a working

knowledge of hospital policy regarding the use of restraint or seclusion.

Interpretive Guidelines §482.13(e)(11)

At a minimum, physicians and other LPs authorized to order restraint and seclusion must have a

working knowledge of hospital policy regarding the use of restraint and seclusion.

Hospitals have the flexibility to identify training requirements above this minimum requirement based

on the competency level of their physicians and other LPs, and the needs of the patient population(s) that

they serve. Physicians receive training in the assessment, monitoring, and evaluation of a patient’s

condition as part of their medical school education. However, physicians generally do not receive

training regarding application of restraint or implementation of seclusion as part of their basic education.

Depending on the level and frequency of involvement that a physician or other LP has in the

performance of these activities, additional training may or may not be necessary to ensure the

competency of these individuals in this area. The hospital is in the best position to determine if

additional physician or other LP training is necessary based on the model of care, level of physician

competency, and the needs of the patient population(s) that the hospital serves.

Survey Procedures §482.13(e)(11)

• Review the hospital policy regarding restraint and seclusion training requirements for physicians

and other LPs. Are the minimum training requirements addressed?

• Review medical staff credentialing and privileging files to determine if physicians or other LPs

involved in restraint and seclusion activities have completed the required training.