Revised restraint requirement for hospitals and critical access hospitals
The Joint Commission has revised standard PC.03.05.19, element of performance 1, related to the use of restraints. The change was made as a result of the CMS final rule titled “Reform of Hospital and Critical Access Hospital Conditions of Participation,” which published in the Federal Register on May 16, 2012. The Joint Commission added a sentence regarding the types of restraints that apply to reporting for deaths that occur within one week of the use of restraints. The revision applies to hospitals and psychiatric and rehabilitation distinct part units in critical access hospitals. The revised requirement (underlined below) is effective immediately.
Standard PC.03.05.19, EP 1: For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital reports the following information to the Centers for Medicare & Medicaid Services (CMS) regarding deaths related to restraint or seclusion (this requirement does not apply to deaths related to the use of soft wrist restraints: for more information, refer to EP 3 in this standard):
- Each death that occurs while a patient is in restraint or seclusion
- Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion
- Each death known to the hospital that occurs within one week after restraint or seclusion was used when it is reasonable to assume that the use of the restraint or seclusion contributed directly or indirectly to the patient’s death. The types of restraints included in this reporting requirement are all restraints except soft wrist restraints.
Note: In this element of performance, “reasonable to assume” includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time or deaths related to chest compression, restriction of breathing, or asphyxiation.
(Contact: Sophie Duco, sduco@jointcommission.org)