In the new Long Term Care survey requirements, there are new requirements for proper documentation of the use of any type of side rail but the coding requirements for Section P0100A have not changed. No device is coded in P0100 unless it meets the definition of a physical restraint.

Physical Restraints: Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident’s body that the individual cannot remove easily, which restricts freedom of movement or normal access to one’s body (RAI P-1)

The following coding tips are offered in the RAI manual concerning bed rails: (RAI, P-5)

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.

Oddly enough, coding bed rails in P0100A at any frequency will not trigger the Long Stay Restraint Quality Measure. (QM User’s Manual V 11.0)

Long-stay residents with a selected target assessment that indicates daily physical restraints, where:

1.Trunk restraint used in bed (P0100B = [2]), or

2.Limb restraint used in bed (P0100C = [2]), or

3.Trunk restraint used in chair or out of bed (P0100E = [2]), or

4.Limb restraint used in chair or out of bed (P0100F = [2]), or

5.Chair prevents rising used in chair or out of bed (P0100G) = [2]).

However, if a bed rail meets criteria for a physical restraint, the record must show all the necessary elements for restraint use:

Prior to using any physical restraint, the nursing home must assess the resident to properly identify the resident’s needs and the medical symptom(s) that the restraint is being employed to address. If a physical restraint is needed to treat the resident’s medical symptom, the nursing home is responsible for assessing the appropriateness of that restraint. When the decision is made to use a physical restraint, CMS encourages, to the extent possible, gradual restraint reduction because there are many negative outcomes associated with restraint use. (RAI, P-1)

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. (RAI, P-4)

For more information on regulatory requirements for any physical restraint, see F604, 43 CFR 483.12(a)(2). If the bedrail is deemed to be a restraint, the resident/representative must be informed of potential risks and benefits of all options under consideration including using a restraint, not using a restraint, and alternatives to restraint use. Pertinent interpretive guidelines for F604 are below:

Determination of Use of Bed Rails as a Restraint

Facilities must use a person-centered approach when determining the use of bed rails, which would include conducting a comprehensive assessment, and identifying the medical symptom being treated by using bed rails. Bed rails may have the effect of restraining one individual but not another, depending on the individual resident’s conditions and circumstances.

Residents who are cognitively impaired are at a higher risk of entrapment and injury or death caused by restraints. Residents in a bed with bed rails have attempted to exit through, between, under, over, or around bed rails or have attempted to crawl over the foot board, which places them at risk of serious injury or death. Serious injury from a fall is more likely from a bed with raised bed rails than from a bed where bed rails are not used. In many cases, the risk of using the bed rails may be greater than the risk of not using them as the risk of restraint-related injury and death is significant. For example, a resident who has no voluntary movement may still 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, increasing the risk for entrapment, when bed rails are used. Also refer to 42 CFR §483.25(n) – Bed Rails (tag F700).

The use of partial bed rails may assist an independent resident to enter and exit the bed independently and would not be considered a physical restraint. To determine if a bed rail is being used as a restraint, the resident must be able to easily and voluntarily get in and out of bed when the equipment is in use. If the resident cannot easily and voluntarily release the bed rails, the use of the bed rails may be considered a restraint.

It is clear that the clinical record must show evidence of resident/representative informed consent for use of any physical restraint. This is often demonstrated by obtaining a ‘restraint consent’ on a form. This is the crux of the current confusion over whether all side rails are coded in P0100. In F700, there is another requirement for informed consent for the use of a side rail even though it is not a restraint.

F700

§483.25(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

§483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

§483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

§483.25(n)(3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight.

§483.25(n)(4) Follow the manufacturers’ recommendations and specifications for installing and maintaining bed rails.

This consent is not a consent for a restraint. This is a consent for use of a bed rail. This consent includes explaining the risk of entrapment, other accident hazards and possible benefits.

Summary: Nothing has changed about the coding instruction for P0100A: Bed rails. All bed rails are not restraints, but we must obtain informed consent for all bed rails. The consent for the bed rail as a restraint is separate and apart from the consent for bed rail use that is not a restraint.