P0100E. Restraint used in chair/ out of bed: trunk restraint

Step-by-Step Coding Guide for P0100E. Restraint used in chair/ out of bed: trunk restraint

1. Review of Medical Records

Begin by thoroughly examining the resident's medical record, including physician orders, nurses' notes, and documentation from nursing assistants. This step is crucial to determine if trunk restraints were used during the 7-day look-back period.

2. Understanding Definitions

Trunk Restraints: Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that the resident cannot easily remove. This includes devices like vest or waist restraints or belts used in a wheelchair that either restrict freedom of movement or access to the body.

3. Coding Instructions

• Code 0 (Not Used): If the trunk restraint was not used during the 7-day look-back period.
• Code 1 (Used Less Than Daily): If the trunk restraint was used less than daily during the observation period.
• Code 2 (Used Daily): If the trunk restraint was used daily during the look-back period.

4. Coding Tips

• Focus on the resident's ability to remove the restraint and whether it restricts freedom of movement or access to their own body.
• Consider the physical condition and the ability of the resident to achieve their objective when evaluating if the restraint can be "removed easily."

5. Documentation

• Ensure there is physician documentation of a medical symptom that supports the use of the restraint.
• Document the type of restraint and parameters of its use, including a physician's order.
• Include a care plan with a systematic and gradual restraint reduction or elimination strategy, as appropriate.

6. Common Errors to Avoid

• Misinterpreting restraints that do not restrict movement or access to the body as trunk restraints.
• Failing to document the medical rationale and physician orders for the use of the restraint.
• Overlooking alternative, less restrictive measures before employing trunk restraints.

7. Practical Application

• Example: If a resident is documented to have worn a vest restraint while in a wheelchair during the entire 7-day look-back period, and the restraint was used to prevent them from leaning forward due to poor trunk control, and the resident could not remove the restraint without assistance, you would:
  1. Verify physician orders and medical justification in the medical record.
  2. Code as "2 (Used Daily)" since the restraint was used every day.
  3. Document the care planning process, including efforts for restraint reduction and the rationale for continued use.

The Step-by-Step Coding Guide for item P0100E in MDS 3.0 Section P is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.