Hand Mitts as Restraints

Is one mitten untied considered a restraint in a patient that is physically able to remove the mitten with the other hand but is pleasantly confused?

The Joint Commission defines a restraint as any method, chemical or physical, of restricting a patient's freedom of movement, including seclusion, physical activity or normal access to his or her body that: is not a usual part of a medical procedures which the patient/legal representative has consented; is not indicated to treat the patient's medical condition/symptoms; does not promote the patient's independent functioning.
According to CMS Conditions of Participation §482.13(e) (1) Definitions. (i) A restraint is-

  • Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or §482.13(e)(1)(i)(B) [A restraint is - ] A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.

NOTE: Generally, if a patient can easily remove a device, the device would not be considered a restraint. In this context, "easily remove" means that the manual method, device, material, or equipment can be removed intentionally by the patient in the same manner as it was applied by the staff (e.g., side rails are put down, not climbed over; buckles are intentionally unbuckled; ties or knots are intentionally untied; etc.) considering the patient's physical condition and ability to accomplish objective (e.g., transfer to a chair, get to the bathroom in time).

CMS Interpretive Guidelines go on to explain that many types of hand mitts would not be considered restraint. However, pinning or otherwise attaching those same mitts to bedding or using a wrist restraint in conjunction with the hand mitts would meet the definition of restraint and the requirements would apply. In addition, if the mitts are applied so tightly that the patient's hand or fingers are immobilized, this would be considered restraint and the requirements would apply. Likewise, if the mitts are so bulky that the patient's ability to use their hands is significantly reduced, this would be considered restraint and the requirements would apply.

To err on the side of caution, if a patient has one mitt that is tied down and one mitt that is not tied down, it is considered a restraint.  You must take into consideration the patient's confused state, the patient's physical condition and the patient's ability to accomplish the objective.  The patient may not be able to remove the mitt that is tied down; may not be able to reach the knot; may not have the dexterity to accomplish the task of removing the mitt.  Restraints are such a slippery slope one should hesitate to say that one mitt tied down is not a restraint.

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