We use many of them. The devices are part of our restraint policy. See below

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1 Do you utilize body pillow, beveled mattresses, moxi mattresses, rolled blankets, swim noodles for positioning or bed demarcation? Do you have a comprehensive device assessment? If so, would you please share. Brown Dane Grant Green Kenosha LaCrosse Lakeview Outagamie St. Croix Sauk In response to your question Do you utilize body pillow, beveled mattresses, moxi mattresses, rolled blankets, swim noodles for positioning or bed demarcation? Do you have a comprehensive device assessment? We do use several devices for positioning. At Brown County, we use body pillows and scoop mattresses (I am assuming that the beveled mattresses are the same) for safety and positioning of our residents. Keeping in mind that these could be considered restraints if the resident can get out of bed and these devices prevent that or inhibit it in any way. We do not have any assessment for use we discuss the need at our IDT meetings and choose the best option for the resident. We use many of them. The devices are part of our restraint policy. See below We use them but don t have a good device assessment. We would be interested in seeing some examples. We do use lipped mattresses, body pillows and rolled blankets for positioning. I am not sure what a moxi bed is. We do have a supportive device assessment in ECS. Below is the one we used when we were paper charting. We do not have a comprehensive device assessment. We do use wide beds, low bed height, sidewall mattresses and floor mats for safety. We usually assess for the use of these when we do either fall risk assessments or post fall assessments. We use Bolster mattress s we have our RN nursing staff assess for the need, then care plan to it. We currently do not use any other device. We use body pillows and lipped mattresses. Noodles and rolled blankets are typically not real effective as they are difficult to keep in place. If we felt the body pillow or lipped mattress could be viewed as a restraint based on an individual s function (rare), we would utilize our restraint assessment. We do not have anything specific to the devices mentioned. Yes we use things for positioning, we do a trial with the resident, care plan it, and put it on the calendar to look at it in 30 days or less to see if the devise is working for the resident, was it an isolated event or do we need to make a change. We use body pillows but they are for positioning. We do no formal assessment as this is a positioning device. recommendations for use of such device come from restorative COTA or therapy department.

2 GREEN COUNTY - PHYSICAL DEVICE ASSESSMENT COGNITIVE STATUS: Alert:!Yes! No Oriented to Time:!Yes! No Place:!Yes!No Person:!Yes! No COMMUNICATION STATUS " Impaired hearing: " Uses hearing aids: " Right and/or " Left " Impaired vision: " Yes " No Wears Glasses: "Yes "No MENTAL / BEHAVIORAL STATUS " Comatose " Impaired decision-making " Indicators of delirium " Periods of altered perception " Memory problem: " Short-term " Long-term " Distracted " Lethargic " Mental function varies " Impaired ability to understand others " Other: SAFETY / FALL HISTORY: (Obtain information from resident, family, medical records - circle information source) " Falls in past 30 days " Physical Impairment " Indicators of delirium " Periods of altered perception " Recent Hospitalization " Injury as a result of a Fall " Other DIAGNOSES / FACTORS / CONDITIONS: CHECK ALL THAT APPLY: " Parkinson s " CVA " Spinal cord injury " Hemiplegia " Later stages of dementia " Cerebral Palsy " Delirium " Paraplegia " COPD " Depression " CVA " Amputation " Multiple Sclerosis " Obesity " Neurological Deficits " Other DEVICE TO PROMOTE FUNCTIONING STATUS " Bed Alarm " Lap Buddy " Reclining Chair " Chair Alarm " Lap Tray " GrabBars " Mat Alarm " Pommel Cushion " Bed Against " Self-Release Seat Belt " Wedge Cushion " Side rail

3 REASON FOR THE USE OF THE DEVICE " Positioning " Alignment " Balance " Comfort " Safety Risk " To Alert the Staff " Fall Risk " Non-weight Bearing " Other How will the use of the device maintain or improve the functional capacity of this resident? What alternatives have been implemented and what was the outcome of their use? Describe the plan for the device, including how it will be monitored for proper use and effectiveness: Nurse Signature Date Pleasant View Nursing Home, Monroe, WI Resident: 4B-Physcial Device assessment Revised: October 2011 PV #: RM: Initial Review Summary of Root Cause Analysis and Interventions Signature Date

4 1 st Review Summary of Root Cause Analysis and Interventions Signature Date 2 nd Review Summary of Root Cause Analysis and Interventions Signature Date 3 rd Review Summary of Root Cause Analysis and Interventions Signature 4B-Physical Device ASSESSMENT Date Resident Revised: October 2011 PV RM

5 BADGER PRAIRIE HEALTH CARE CENTER POLICIES AND PROCEDURES SUBJECT: Restraint/Device Use I. PURPOSE: To ensure that the least restrictive restraints and positioning devices are utilized, to identify components of the assessment, and to define a process for evaluation and reduction. II. POLICY: Each resident will attain and maintain his/her highest level of well being in an environment that is free from physical or chemical restraints. Restraints will only be used if they benefit the resident by addressing a medical symptom. Restraints will not be used without first seeking to identify and address the physical or psychological condition causing the medical symptom. Restraints will not be used without a thorough assessment that includes consideration and/or trials of less restrictive measures. Restraints will be reassessed at least quarterly and there will be a systematic and gradual process to reduce restraints. Residents in restraints will have comfort needs provided at least every 2 hours and have designated periods during the day and a method that allows the resident to be free of restraints. Assistive devices will be thoroughly assessed and treated as a restraint if they have a restraining effect. Restraints are anything that meets the definition, regardless of how they are coded on the MDS. III. REFERENCES: State Operations Manual RAI CMS Memo of November 26, 2014 IV. FORMS: Restraint/Device Flow Sheet Frequent Checks Form Resident Care Plan Interdisciplinary Notes 24-Hour Report Sheet MDS V. PROCEDURES: A. Definition: Physical restraints are 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. Restraints can include and are not limited to: 1. Bed rails of any length 2. Alarms 3. Soft ties, seat belts, lap buddy 4. Limb restraint 5. Chair that prevents rising 6. Lap trays 7. Mitts on hands

6 8. Raised perimeter mattress B. Definition of devices: Any method of assistance in positioning or mobility used to promote the resident s highest level of functioning. A device could be both a restraint and an enabler. A device that meets the definition of a restraint can be quite appropriate and the least restrictive intervention. Any device that has a restraining effect must be MD ordered and treated as a restraint. Devices can include but are not limited to: 1. Transfer bars 2. Bolsters 3. Raised perimeter mattress 4. Wedge cushion 5. Orthotic body devices used solely for therapeutic purposes to improve the overall functional capacity of the resident C. Evaluation of need for restraint/device. 1. Other less restrictive alternatives will be explored before restraints or devices are applied. Alternatives include: Physical/Comfort # Positioning # Evaluation of Meds # Toileting # Pain Relief # Change in Treatment # Back Rub # Sensory Aids # Appropriate Clothing # Relief of Hunger/Thirst Activities # Ambulation # Distraction # Recreation/Social Activity # Exercise # Soft Music # 1:1 Staff Contact Environment # Soothing Background Music # Noise Reduction # Controlled Lighting # Personal Space # Personal Belongings # Mobility Aids # Change Physical Environment/Temperature # Positioning Aids Psych/Social # Provide Sense of Security/Reassurance # Attention to Resident Activity Plan/Desires # Active Listening (feeling, concerns) # Companionship (one on one) # Reality Orientation # Facilitating Resident Control Over ADLs # Family/Significant Other Interactions 2. Document response to alternatives in interdisciplinary notes. 3. Obtain an OT/PT evaluation order or MD/Psych assessment as indicated. 4. If no lesser restrictive alternatives meet the resident s needs, the nurse should complete restraint assessment, inform legal decision-maker, obtain MD order. 5. In an emergency, a restraint may be initiated with an MD order from psychiatrist and a documented nursing assessment. Emergency restraints are defined as immediately necessary to prevent a resident from injuring him/herself or others

7 and/or to prevent the resident from interfering with life-sustaining treatment and no other less restrictive or less risky interventions exist. D. Use of Restraints/Devices: 1. Application: Explain the reason for the restraint/device to the resident. Document the resident s response to the restraint/device. 2. Monitoring: Restraints and devices that have potential to cause strangulation or entrapment will be checked at least every 2 hours and provision of comfort needs, range of motion, repositioning, and appropriate exercise and ambulation provided at that time. There will be designated periods during the day and a method care planned that allows the resident to be free from restraints. 3. Reassessment: Restraints will be reassessed quarterly and the systematic plan for reduction reviewed. E. Documentation for Restraints. 1. If a resident is admitted with a restraint order, the RN will complete a restraint assessment in the IPN notes in the restraint/device category at admission. 2. A restraint assessment must be completed in IPN notes prior to receiving any MD order for restraints including order changes, reduction, etc. An initial restraint assessment should include: a. When used b. Why used (medical reason) c. Identify symptoms being treated d. Record alternative and less restrictive interventions that were attempted and unsuccessful e. Identify risks and benefits to using restraint and explain how benefits outweigh the risks 3. The MD order will include the type of restraint, when it is to be applied, and a supporting medical diagnosis/symptom for its use. 4. If a restraint is applied PRN, nurse must write an IPN to address with E.2 above. 5. The guardian/poa will be notified of the risk/benefit of restraint use. This information will be recorded in IPN notes in the Restraint/Device category. The guardian will be notified when the restraint is initiated, discontinued, and at the annual MDS. 6. Nursing staff will record the use of restraints and indicate that the resident was checked at least every 2 hours on the restraint/device flow sheet (attached) for each shift. 7. Staff will use the Frequent Checks Form to monitor residents at high risk who need more frequent checks than every 2 hours and/or who have recently had restraints reduced. Some examples would be incidents of extremities through rails, restless or flailing movements.

8 8. Update care plan including restraint free times. 9. A systematic and gradual process towards reducing the need for the restraint needs to be care planned and its implementation documented at least annually. 10. Restraints will be reassessed when indicated or at least quarterly on MDS schedule in IPN notes in restraint/device category. Quarterly restraint assessments should include any changes in continence, skin condition, pain, eating, drinking, sleeping, ambulation, self-care, mood, behavior, cognition, need for medications. Were any of these related to the restraint? Review attempts at restraint reduction during last quarter. Update plan of care and CNA assignment sheet for frequency of checks, comfort needs, restraint free periods, and plan for restraint reduction. F. Documentation for Devices: 1. Therapy, CCC, or RN will document the need for an assistive device in IPN notes under restraint/device category before implementation. This assessment should include: a. Type of device b. When used c. Why used medical reason d. Is resident achieving his/her highest level of functioning because of the device? e. Are there any negative effects caused by the use of the device? f. Do the benefits outweigh the risks? g. There must be a clear statement that the device does not function as a restraint (see definition on page 1 of this policy) 2. The MD order will include type of device, when it is used, and supporting medical diagnosis and symptoms for its use. 3. Therapy, CCC, or RN will notify guardian/poa of risk/benefit of device use. This information will be recorded in IPN notes under Restraint/Device category. The guardian will be notified when the device is initiated, discontinued, and at the annual MDS. 4. Device added to care plan and CNA care plan. 5. Staff will record use of side rails and grab bars that function as devices on restraint/devices flow sheet. 6. Devices will be reassessed as needed or at least quarterly on MDS schedule in IPN notes in Restraint/Device category. Quarterly device assessments should include any changes in continence, skin condition, pain, eating, drinking, sleeping, ambulation, self-care, mood, behavior, cognition, need for medications. Were any of these related to the device? Does the device still assist the resident in achieving highest level of functioning? Update plan of care and CNA care plan if there are any changes in use of device. VI. COORDINATION: Nursing Social Workers OT/PT

9 FREQUENT CHECKS FORM Name: Frequency: Date Date Date Tim e Init. Observations Time Init. Observations Time Init. Observations

10 RESIDENTS NAME: DATE: DEFINITION OF A RESTRAINT: 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. Any device can be considered a restraint, even it it s primary use is to assist a resident to reach his or her highest level of functioning. Therefore, all restraints and devices must be assessed BEFORE applied, changed, or discontinued, and quarterly. $ $ Notify the guardian/poa what the restraint/device is, when and why it is being used, and the risk and benefits of it s use BEFORE a restraint/device is applied, changed, discontinued and at a full MDS. Both assessments and guardian notifications need to be recorded in IPN notes under the Restraint/Device category. $ MD orders are required for all restraints and devices. Initial & Quarterly Restraint/Device Assessment Key $ Identify restraint/device, how long it is to be used and under what circumstances. $ Identify medical symptoms being treated and how restraint/device benefits resident by treating the medical symptom. $ Assess risks and benefits to using the restraint/device and explain how benefits outweigh risks. $ Identify alternative and less restrictive measures that have been attempted and were unsuccessful. $ Determine if the device is functioning as a restraint. $ Include any changes since last review. Were any of these related to the restraint/device?. $ Review attempts at restraint reduction during the last quarter. If it is a device, does it still assist the resident in achieving their highest level of functioning? $ Is the CNA care plan accurate? $ Is the MD order correct? $ Is the restraint/device flow sheet accurate? $ Did you contract the guardian/poa with changes and at least annually? If the Restraint/Device Functions as a Restraint, You Must Also: $ Care plan how frequently the resident needs to be checked (minimally every 2 hours) and what comfort needs will be provided when the resident is checked. $ Care plan designated period(s) during the day that the resident will be free from restraints and the method that allows the resident to be restraint free. $ Care plan a system for gradual restraint reduction. A reduction needs to be tried at least annually.

11 Quarterly Restraint Reassessment Key $ Include any changes in continence, skin condition, pain, eating, drinking, sleeping, ambulation, self-care, mood, behavior, cognition, need for medications. Were any of these related to the restraint/device? $ Review attempts of restraint reduction during the last quarter. Does the device still assist the resident in achieving their highest level of functioning? $ Update plan of care for frequency of checks, comfort needs, restraint free periods, and plan for restraint reduction in the future. $ Does the CNA assignment sheet match the care plan? $ Is the MD order correct? $ Is the restraint/device flow sheet accurate? $ Did you contact the guardian/poa at changes and at least annually?