CMS SOM App. M, Tag L840

All patients have the right to be free from physical or mental abuse, and corporal

punishment. All patients have the right to be free from restraint or seclusion, of any

form, imposed as a means of coercion, discipline, convenience, or retaliation by

staff. Restraint or seclusion may only be imposed to ensure the immediate physical

safety of the patient, a staff member, or others and must be discontinued at the

earliest possible time.

Interpretive Guidelines §418.110(n)

The hospice is responsible for creating a culture that supports a patient’s right to be free

from restraint or seclusion and ensures patients are free from physical or mental abuse

and corporal punishment. The hospice must also ensure that systems and processes are

developed, implemented, and evaluated that support the patients’ rights addressed in this

standard, and that eliminate the inappropriate use of restraint or seclusion.

If restraint or seclusion is necessary within the parameters of this regulation (§488.110),

it must be discontinued as soon as possible based on an individualized patient assessment

and re-evaluation. A violation of any of these patients’ rights constitutes an inappropriate

use of restraint or seclusion and would be subject to a condition level deficiency.

The use of restraints for the prevention of falls must not be considered a routine part of a

falls prevention program. Although restraints have been traditionally used as a falls

prevention approach, they have major, serious drawbacks and can contribute to serious

injuries. There is no evidence that the use of physical restraint, (including, but not

limited to, raised side rails) will prevent or reduce falls. Additionally, falls that occur

while a person is physically restrained often result in more severe injuries and/or death.