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DiraChart MDS item reference
P0100HSection Pv1.20.1Manual page P-2
Restraints in chair/out of bed: other
This item is referenced against CMS MDS source materials. Verify coding against the current CMS RAI Manual, item set instructions, and facility documentation before submission.
Quick coding
Answer Codes
Use the item-specific response choices below when structured codes apply.
Response format: Coded response
1
used less than daily
Manual page P-22
used daily
Manual page P-2Item-specific instructions
Coding Guidance
Review what the item asks, how to choose the response, and what should be verified before submission.
Steps for Assessment
1. Review the resident’s medical record (e.g., physician orders, nurses’ notes, nursing assistant
documentation) to determine if physical restraints were used during the 7-day look-back
period.
2. Consult the nursing staff to determine the resident’s cognitive and physical status/limitations.
3. Considering the physical restraint definition as well as the clarifications listed below, observe
the resident to determine the effect the restraint has on the resident’s normal function. Do not
focus on the type, intent, or reason behind its use.
4. Evaluate whether the resident can easily and voluntarily remove any manual method or
physical or mechanical device, material, or equipment attached or adjacent to their body. If
the resident cannot easily and voluntarily do this, continue with the assessment to determine
whether or not the manual method or physical or mechanical device, material or equipment
restrict freedom of movement or restrict the resident’s access to their own body.
5. Any manual method or physical or mechanical device, material or equipment should be
classified as a restraint only when it meets the criteria of the physical restraint definition.
This can only be determined on a case-by-case basis by individually assessing each and every
manual method or physical or mechanical device, material or equipment (whether or not it is
listed specifically on the MDS) attached or adjacent to the resident’s body, and the effect it
has on the resident.
6. Determine if the manual method or physical or mechanical device, material, or equipment
meets the definition of a physical restraint as clarified below. Remember, the decision about
coding any manual method or physical or mechanical device, material, equipment as a
restraint depends on the effect it has on the resident.
7. Any manual method or physical or mechanical device, material, or equipment that meets the
definition of a physical restraint must have:
•
physician documentation of a medical symptom that supports the use of the restraint,
•
a physician’s order for the type of restraint and parameters of use, and
•
a care plan and a process in place for systematic and gradual restraint reduction (and/or
elimination, if possible), as appropriate.
P0100: Physical Restraints (cont.)
Clarifications
•
“Remove easily” means that the manual method or physical or mechanical device,
material, or equipment can be removed intentionally by the resident in the same manner
as it was applied by the staff (e.g., side rails are put down or not climbed over, buckles
are intentionally unbuckled, ties or knots are intentionally untied), considering the
resident’s physical condition and ability to accomplish their objective (e.g., transfer to a
chair, get to the bathroom in time).
•
“Freedom of movement” means any change in place or position for the body or any part
of the body that the person is physically able to control or access.
•
“Medical symptoms/diagnoses” are defined as an indication or characteristic of a
physical or psychological condition. Objective findings derived from clinical evaluation
of the resident’s subjective symptoms and medical diagnoses should be considered when
determining the presence of medical symptom(s) that might support restraint use. The
resident’s subjective symptoms may not be used as the sole basis for using a
restraint. In addition, the resident’s medical symptoms/diagnoses should not be
viewed in isolation; rather, the medical symptoms identified should become the
context in which to determine the most appropriate method of treatment related to
the resident’s condition, circumstances, and environment, and not a way to justify
restraint use.
•
The identification of medical symptoms should assist the nursing home in determining if
the specific medical symptom can be improved or addressed by using other, less
restrictive interventions. The nursing home should perform all due diligence and
document this process to ensure that they have exhausted alternative treatments and less
restrictive measures before a physical restraint is employed to treat the medical symptom,
protect the resident’s safety, help the resident attain or maintain their highest level of
physical or psychological well-being and support the resident’s goals, wishes,
independence, and self-direction.
•
Physical restraints as an intervention do not treat the underlying causes of medical
symptoms. Therefore, as with other interventions, physical restraints should not be
used without also seeking to identify and address the physical or psychological
condition causing the medical symptom.
•
Physical restraints may be used, if warranted, as a temporary symptomatic intervention
while the actual cause of the medical symptom is being evaluated and managed.
Additionally, physical restraints may be used as a symptomatic intervention when they
are immediately necessary to prevent a resident from injuring themself or others and/or to
prevent the resident from interfering with life-sustaining treatment when no other less
restrictive or less risky interventions exist.
P0100: Physical Restraints (cont.)
•
Therefore, a clear link must exist between physical restraint use and how it benefits the
resident by addressing the specific medical symptom. If it is determined, after thorough
evaluation and attempts at using alternative treatments and less restrictive methods, that a
physical restraint must still be employed, the medical symptoms that support the use of
the restraint must be documented in the resident’s medical record, ongoing assessments,
and care plans. There also must be a physician’s order reflecting the use of the physical
restraint and the specific medical symptom being treated by its use. The physician’s order
alone is not sufficient to employ the use of a physical restraint. CMS will hold the
nursing home ultimately accountable for the appropriateness of that determination.
Coding Instructions
Identify all physical restraints that were used at any time (day or night) during the 7-day look-
back period.
After determining whether or not an item listed in (P0100) is a physical restraint and was used
during the 7-day look-back period, code the frequency of use:
•
Code 0, not used: if the item was not used during the 7-day look-back period or it
was used but did not meet the definition.
•
Code 1, used less than daily: if the item met the definition and was used less than
daily during the observation period.
•
Code 2, used daily: if the item met the definition and was used on a daily basis
during the look-back period.
Coding Tips
and Special Populations
•
Any manual method or physical or mechanical device, material or equipment, that does
not fit into the listed categories but that meets the definition of a physical restraint, and
has not been excluded from this section, should be coded in items P0100D or P0100H,
Other. These devices, although not coded on the MDS, must be assessed, care-planned,
monitored, and evaluated.
•
In classifying any manual method or physical or mechanical device, material or
equipment as a physical restraint, the assessor must consider the effect it has on the
resident, not the purpose or intent of its use. It is possible that a manual method or
physical or mechanical device, material or equipment may improve a resident’s mobility
but also have the effect of physically restraining them.
•
Exclude from this section items that are typically used in the provision of medical care,
such as catheters, drainage tubes, casts, traction, leg, arm, neck, or back braces,
abdominal binders, and bandages that are serving in their usual capacity to meet medical
need(s).
•
When coding this section, do not consider as a restraint a locked/secured unit or building
in which the resident has the freedom to move about the locked/secured unit or building.
Additional guidance regarding locked/secured units is provided in the section
“Considerations Involving Secured/Locked Areas” of F603 in Appendix PP of the State
Operations Manual.
P0100: Physical Restraints (cont.)
•
Bed rails include any combination of partial or full rails (e.g., one-side half-rail, one-side
full rail, two-sided half-rails or quarter-rails, rails along the side of the bed that block
three-quarters to the whole length of the mattress from top to bottom, etc.). Include in this
category enclosed bed systems.
— Bed rails used as positioning devices. If the use of bed rails (quarter-, half- or three-
quarter, one or both, etc.) meet the definition of a physical restraint even though they
may improve the resident’s mobility in bed, the nursing home must code their use as a
restraint at P0100A.
— Bed rails used with residents who are immobile. If the resident is immobile and
cannot voluntarily get out of bed because of a physical limitation or because proper
assistive devices were not present, the bed rails do not meet the definition of a
physical restraint.
For residents who have no voluntary movement, the staff need to determine if there is
an appropriate use of bed rails. Bed rails may create a visual barrier and deter
physical contact from others. Some residents have no ability to carry out voluntary
movements, yet they exhibit involuntary movements. Involuntary movements,
resident weight, and gravity’s effects may lead to the resident’s body shifting toward
the edge of the bed. When bed rails are used in these cases, the resident could be at
risk for entrapment. For this type of resident, clinical evaluation of alternatives (e.g., a
concave mattress to keep the resident from going over the edge of the bed), coupled
with frequent monitoring of the resident’s position, should be considered. While the
bed rails may not constitute a physical restraint, they may affect the resident’s quality
of life and create an accident hazard.
•
Trunk restraints include any manual method or physical or mechanical device, material
or equipment attached or adjacent to the resident’s body that the resident cannot easily
remove such as, but not limited to, vest or waist restraints or belts used in a wheelchair
that either restricts freedom of movement or access to their body.
•
Limb restraints include any manual method or physical or mechanical device, material
or equipment that the resident cannot easily remove, that restricts movement of any part
of an upper extremity (i.e., hand, arm, wrist) or lower extremity (i.e., foot, leg) that either
restricts freedom of movement or access to their own body. Hand mitts/mittens are
included in this category.
•
Trunk or limb restraints, if used in both bed and chair, should be marked in both
sections.
P0100: Physical Restraints (cont.)
•
Chairs that prevent rising include any type of chair with a locked lap board, that places
the resident in a recumbent position that restricts rising, chairs that are soft and low to the
floor, chairs that have a cushion placed in the seat that prohibit the resident from rising,
geriatric chairs, and enclosed-frame wheeled walkers.
— For residents who have the ability to transfer from other chairs, but cannot transfer
from a geriatric chair, the geriatric chair would be considered a restraint to that
individual, and should be coded as P0100G–Chair Prevents Rising.
— For residents who have no ability to transfer independently, the geriatric chair does
not meet the definition of a restraint, and should not be coded at P0100G–Chair
Prevents Rising.
— Geriatric chairs used for residents who are immobile. For residents who have no
voluntary or involuntary movement, the geriatric chair does not meet the definition of
a restraint.
Enclosed-frame wheeled walkers, with or without a posterior seat, and other devices
like it should not automatically be classified as a physical restraint. These types of
walkers are only classified as a physical restraint if the resident cannot exit the walker
via opening a gate, bar, strap, latch, removing a tray, etc. When deemed a physical
restraint, these walkers should be coded at P0100G–Chair Prevents Rising.
•
Restraints used in emergency situations. If the resident needs emergency care, physical
restraints may be used for brief periods to permit medical treatment to proceed, unless the
resident or legal representative has previously made a valid refusal of the treatment in
question. The resident's right to participate in care planning and the right to refuse
treatment are addressed at 42 CFR 483.10(c)(6) and 483.21(b)(ii)(A)–(F) respectively.
The use of physical restraints in this instance should be limited to preventing the resident
from interfering with life-sustaining procedures only and not for routine care.
— A resident who is injuring themself or is threatening physical harm to others may be
physically restrained in an emergency to safeguard the resident and others. A resident
whose unanticipated violent or aggressive behavior places them or others in imminent
danger does not have the right to refuse the use of physical restraints, as long as those
restraints are used as a last resort to protect the safety of the resident or others and use
is limited to the immediate episode.
Additional Information
•
Restraint reduction/elimination. It is further expected, for residents whose care plan
indicates the need for physical restraints, that the nursing home engages in a systematic
and gradual process towards reducing (or eliminating, if possible) the restraints (e.g.,
gradually increasing the time for ambulation and strengthening activities). This
systematic process also applies to recently-admitted residents for whom physical
restraints were used in the previous setting.
P0100: Physical Restraints (cont.)
•
Restraints as a fall prevention approach. Although physical restraints have been
traditionally used as a fall prevention approach, they have major drawbacks and can
contribute to serious injuries. Falls do not constitute self-injurious behavior nor a medical
symptom supporting the use of physical restraints. There is no evidence that the use of
physical restraints, including but not limited to side rails, will prevent, reduce, or
eliminate falls. In fact, in some instances, reducing the use of physical restraints may
actually decrease the risk of falling. Additionally, falls that occur while a person is
physically restrained often result in more severe injuries.
•
Request for restraints. While a resident, family member, legal representative, or
surrogate may request use of a physical restraint, the nursing home is responsible for
evaluating the appropriateness of that request, just as they would for any medical
treatme
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