Skip to Navigation | Skip to Content

Joint Commission and CMS Alignment: Restraint Management

Accreditation Monthly

June 9, 2009

Before tracers, restraint was one of the most frequently cited requirements for improvement (RFI), formerly known as a "Type 1" recommendation. Since The Joint Commission recently made significant changes to align more closely to CMS' Conditions of Participation, we have a hunch restraint citations may make it back to the top 10 list.

The March update replaces the January update published by The Joint Commission. Be sure you have that information, available on the agency's Web site.

The following is a summary of the direct impact elements of performance (EP). All direct impact requirements for this subject are Category A.

  • EP.03.05.01 focuses on the indications for each episode of restraint, including discontinuation of restraint at the earliest possible time.
  • EP.03.05.03, EP.1 requires the use of safe techniques to restrain patients according to hospital policies and procedures.
    Suggestion: Implement a well-designed education program that aligns practice across the organization. Provide documentation/competencies of the education. Remember that the medical staff needs restraint education as well. This can be an abbreviated educational document provided to physicians. Don't forget about security guards or other non-licensed personnel that observe patients in restraints or assist with the application of restraints. EP.03.05.05, EP.5 applies only to restraint used for the management of violent or self-destructive behavior. It requires an in-person evaluation by the physician at least every 24 hours. Remember, EP 4 defines the age specific time-limited orders.
  • EP.03.05.05, EP.6 requires renewal of medical (non violent) restraint according to hospital policy. A single instance of a missing order could generate a direct impact RFI.
    Suggestion: Consider the use of protocol orders with specific criteria for discontinuation. There is no longer a requirement that orders be renewed each calendar day, but you must follow your policy.
  • EP.03.05.11, EP.1 requires a face-to-face evaluation of violent or self-destructive patients by a responsible physician or an appropriately trained RN or physician assistant (PA) within one hour of the application of the restraint/seclusion.
    Suggestion: Ensure that all RNs who staff the emergency department or the behavioral healthcare unit have documented training and competencies in evaluating violent or self-destructive patients.
  • EP.03.05.11, EP.2 requires a nurse or PA who performs the one-hour face-to-face evaluation of violent or self-destructive patients to consult with the responsible physician as soon as possible after initiation of restraint.
  • EP.03.05.11, EP.3 specifies the content of the one-hour evaluation of violent patients.
    Suggestion: Hard code this documentation into forms or computer templates. Include the four required components of the face-to-face evaluation defined in EP3.
  • EP.03.05.13, EP.1 requires the continuous observation of patients who are simultaneously restrained and secluded.

There are plenty of other requirements to worry about. But we suggest starting here, with the Category A direct impact requirements.

Document Library | An excellent resource

Document library books

Membership entitles you to unlimited online access to our extensive library of accreditation, medical staff, credentialing, quality, and patient safety policies, procedures, and resources. This library is continuously updated with new and revised documents.

View our Document Library

Question of the Month | Expert Advice & Guidance

  • Question of the Month- September, 2013

    Understanding the Difference between Incidents & Issues

    What is the difference between an Incident and an Issue?

  • Wouldn?t it be great if we had a standard language for things like this! Unfortunately, many of the terms that are used in healthcare ... Read More...