Ask the Experts, MDS 2.0, MDS 3.0 Items

When should we code side rails as restraints?

Editor’s note: The following answer was provided by Jennifer A. Butt, RN, RAC-CT, C-NE, clinical reimbursement manager for the consulting division of Landmark Health Solutions in Haverhill, MA. For more information about Ms. Butt, please see our About page.

Q: We have orders for particular residents that state side rails are “to be used for bed mobility and defining parameters.” We code that side rails are used daily but does this get coded as a restraint also? The residents are generally not able to put them down by themselves.

A: Any device can be considered a restraint depending on the effect the device has on the resident, even if it improves the resident’s mobility. A device should be coded on the MDS as a restraint if it meets the criteria of a restraint per CMS guidelines which is “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.”

CMS further defines “remove easily” and “freedom of movement” as the following:

  • Freedom of Movement means any change in place or position for the body or any part of the body that the person is physically able to control.
  • Remove Easily means that the manual method, device, material, or equipment can be removed intentionally by the resident in the same manner as it was applied by the staff (e.g., siderails are put down, not climbed over; buckles are intentionally unbuckled; ties or knots are intentionally untied; etc.) considering the resident’s physical condition and ability to accomplish objective (e.g., transfer to a chair, get to the bathroom in time).

Each resident must be assessed to determine if the siderail has the effect of a restraint.