Psychotropic Meds: Chemical Restraint and Staff “Convenience” – CMS F605
New CMS guidance for surveyors in long-term care aims to prevent the unnecessary use of psychotropic medications. It calls for scrutiny of any situation in which a psychotropic medication is a “chemical restraint” being used for “convenience”.
The guidance affirms a resident’s “right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.” Here are essential ideas that can help skilled nursing care teams avoid “convenience” citations in surveys.
What is “convenience”?
Surveyor Guidance defines convenience as “the result of any action that has the effect of altering a resident’s behavior such that the resident requires a lesser amount of effort or care, and is not in the resident’s best interest.” Surveyors are advised to specifically look for medications that cause sedation.
“Convenience” - intentional or not
“Convenience” may be flagged when a resident shows symptoms of sedation, e.g., excessive sleeping, drowsiness, withdrawal, decreased activity—meaning that it also may take less effort to meet a resident’s behavioral needs. Whether the impact is intentional or not, CMS says it’s the observed effect that counts.
CMS says that “facilities are responsible for knowing the effects medications have on their residents.” They add: “If a medication has a sedating or subduing effect on a resident and is not being administered to treat a medical symptom, the medication is acting as a chemical restraint.”
The concept of “convenience” applies to other aspects of resident care, too, such as use of physical restraints. If the effect of the care chosen for a resident makes staff’s work easier, “convenience” may be questioned.
What is “discipline”?
“Discipline” refers to any action, such as the administration of a medication, taken by facility staff for the purpose of punishing or penalizing residents, says the CMS guidance. An example CMS provides is: “A resident has been wandering into other resident’s rooms and staff administer a medication to restrict the resident to their room.”
Nonpharmacological interventions first
When practitioners are aiming to treat behavioral symptoms, CMS guidance emphasizes that nonpharmacological interventions should be attempted first “because they are less dangerous to a resident’s health and safety.” (Learn more about dangerous outcomes of antipsychotic use and effects on ADLs in the GuideStar blog.)
A “convenience” citation could occur if instead of attempting a nonpharmacological intervention, a practitioner prescribes a psychotropic medication and it has the effect of causing sedation and/or requiring less staff effort. The medication would be classified as a chemical restraint.
Is a diagnosis enough?
"Diagnoses alone do not necessarily warrant the use of a psychotropic medication," notes CMS. Staff must also document “adequate indications for use”. This means the clinical rationale for administering a medication is based upon an assessment of the resident’s condition and therapeutic goals, and any other treatments have been deemed clinically contraindicated.
F605 citations
F605 addresses the key ideas of keeping residents free from chemical restraints and preventing the unnecessary use of psychotropic medications, CMS explains. Surveyors are advised that if a medication has caused symptoms consistent with prolonged sedation, they may cite noncompliance at a minimum of severity level 3 (harm).
Guidance instructs surveyors to investigate whether a resident has experienced psychosocial harm related to side effects of medications, exploring whether the medication has:
- Affected a resident’s abilities to perform ADLs or to interact with others
- Caused the resident to withdraw or decline from usual social patterns
- Caused the resident to decrease engagement in activities
- Caused diminished ability to think or concentrate.
An example of a Level 4 deficiency provided by CMS is as follows: A resident who was functioning independently began having episodes of wandering into other residents’ rooms and became argumentative when redirected. Staff reported difficulty monitoring the resident while taking care of other residents and requested a psychotropic medication. A surveyor observes the resident sleeping, being difficult to arouse, and requiring new assistance with eating. In the medical record, there is no documentation of attempts at nonpharmacological interventions; there is no other medical reason for the resident’s decline and sedation. This becomes a citation.
To cite a deficiency, the surveyor does not have to prove that an adverse consequence was directly caused by a medication or combination of medications. Instead, the citation focuses on a failure in the care process, says CMS.
Documentation crucial
With the new survey guidance for long-term care, “Major pitfalls lie in lack of updated documentation,” reports Skilled Nursing News. Surveyors will be “digging into medical records on site to ensure documentation is reflective of decision making between staff, residents and their representatives.”
When a psychotropic medication is linked to a diagnosis such as schizophrenia, meeting documentation standards for diagnosis (F658, meeting professional standards ) is essential. These standards are a response to the long-standing prevalence of using psychotropic medication along with an unsubstantiated diagnosis of schizophrenia.
If a resident is receiving a psychotropic medication for behavioral symptoms, there must be documentation that the facility has attempted nonpharmacological interventions, says CMS. Care teams need to document that these attempts were not successful in order to demonstrate that the medication was necessary.
A key takeaway is that if a resident exhibits symptoms of sedation and at the same time, less work is required of staff—whether that was the intended result or not—this may be categorized as “convenience”. A facility is at risk for citation. Defined standards related to diagnosis, exploring alternatives to psychotropic drugs, monitoring for effects, and ensuring gradual dose reduction must all be documented as part of CMS compliance.
As your facility team prepares for CMS surveys, feel free to call on GuideStar Eldercare. We’re here to help.