CMS SOM App. A, Tag A-0202

knowledge based on the specific needs of the patient population in at least the following:]

§482.13(f)(2)(iv) - The safe application and use of all types of restraint or seclusion used in the

hospital, including training in how to recognize and respond to signs of physical and psychological

distress (for example, positional asphyxia).

Interpretive Guidelines §482.13(f)(2)(iv)

Patients have a right to the safe application of restraint or seclusion by trained and competent staff.

Survey Procedures §482.13(f)(2)(iv)

• Is all staff, including contract or agency personnel, identified by the hospital as direct caregivers

trained and able to demonstrate competency in the safe use of all types of restraints or seclusion

used in the hospital?

• Does the hospital educational program address recognition and response to patient signs of

physical and psychological distress?

• Is staff able to identify signs of physical and psychological distress in a timely manner?

• Is staff able to respond to and appropriately treat signs of physical and psychological distress?

• Review hospital data (i.e., incident reports, patient injury or death reports, etc.) to identify any

patterns of patient injuries or death that may indicate that staff are not adequately trained to

recognize and respond to patient signs of physical and psychological distress.