[Insert
Hospital
Logo]
I.
[Insert Policy Manual Title]
Title:
RESTRAINT AND SECLUSION
No.
CQ-4.004
Page:
1 of 9
Origination Date:
06-21-12;
03-01-12; 02-10-09; 04-28-06
Effective Date:
xx-xx-xx
Retires Policy Dated:
xx-xx-xx
Previous Versions Dated:
xx-xx-xx
Hospital Governing Board
Approval Date:
xx-xx-xx
Medical Staff Approval Date: xx-xx-xx
SCOPE:
This policy applies to [insert facility/hospital name here] (“Hospital”). It is a hospital-wide policy
that would apply to any department providing patient care.
II.
PURPOSE:
The purpose of this policy is to define the Hospital’s approach to the application of restraint and
seclusion for patients in a way that protects the patient’s health and safety, and preserves his or her
dignity, rights and well-being.
III.
DEFINITIONS:
A.
“Restraint” means any method, physical or chemical, 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. If the effect of using an object fits the
definition of restraint for a specific patient at a specific time, then for that patient at
that time, the device is a restraint. The definition renders unnecessary the otherwise
impossible task of naming each device and practices that can inhibit a patients’
movement. (See Attachment C)
B.
“Seclusion” is the involuntary confinement of a patient alone in a room or an area
where the patient is physically prevented from leaving. For example, a staff member
standing in front of the unlocked door of a patient’s room with the intent of not
allowing the patient to leave the room has placed the patient in seclusion. Seclusion
may only be used for the management of violent or self-destructive behaviors.
NOTE:
IV.
Restraint Standards do not apply to the following defined situations:
 Voluntary mechanical support
 Age appropriate protective safety interventions
 Forensic and correction restrictions used by law enforcement (see
Attachment C)
POLICY:
It is the policy of this organization to limit the use of restraint and seclusion to those situations
where it is necessary to ensure the immediate physical safety of the patient, staff members, or others
with appropriate and adequate clinical justification and to facilitate the discontinuation of restraint
or seclusion as soon as possible based on an individualized patient assessment and re-evaluation.
[Insert
Hospital
Logo]
V.
[Insert Policy Manual Title]
Title:
RESTRAINT AND SECLUSION
No.
CQ-4.004
Page:
2 of 9
Origination Date:
06-21-12;
03-01-12; 02-10-09; 04-28-06
Effective Date:
xx-xx-xx
Retires Policy Dated:
xx-xx-xx
Previous Versions Dated:
xx-xx-xx
Hospital Governing Board
Approval Date:
xx-xx-xx
Medical Staff Approval Date: xx-xx-xx
PROCEDURE:
A.
B.
Methodology
1.
If indicated, apply restraints using the guidelines documented in the
manufacturer’s instructions.
2.
Document the physician’s order for restraint on the Physician’s Order Sheet
for Restraint or Seclusion.
3.
Once the patient is under control and safe, begin documentation on the
Restraint Flowsheet.
4.
As early as feasible in the restraint process, make the patient aware of the
rational for the intervention.
5.
RN assessments are documented on the Restraint and Seclusion Flowsheet
following the Observation and Monitoring guidelines.
6.
Once the patient meets the criteria for release, the restraint is discontinued.
The decision to discontinue the intervention must include a determination
that the patient’s behavior is no longer a threat to himself/herself.
7.
When a restraint is implemented, the patient’s plan of care must be modified
to reflect this change.
8.
Document in the patient’s medical record any injuries that occur during the
restraint or seclusion episode, as well as the treatment provided for those
injuries.
Authorization and Ordering of Restraints
1.
Restraint is initiated only upon the order of a physician or other licensed
independent practitioner (LIP).
a.
In an emergent situation, and when a physician or LIP is not readily
available, a Registered Nurse competent in restraint usage may
initiate restraint use based on an appropriate assessment of patient
needs. The comprehensive assessment shall include physical
[Insert
Hospital
Logo]
[Insert Policy Manual Title]
Title:
RESTRAINT AND SECLUSION
No.
CQ-4.004
Page:
3 of 9
Origination Date:
06-21-12;
03-01-12; 02-10-09; 04-28-06
Effective Date:
xx-xx-xx
Retires Policy Dated:
xx-xx-xx
Previous Versions Dated:
xx-xx-xx
Hospital Governing Board
Approval Date:
xx-xx-xx
Medical Staff Approval Date: xx-xx-xx
assessment to identify medical problems that may be causing a
change in the patient’s behavior. (Note: A history of falling without a
current clinical basis for restraint interventions is inadequate to
demonstrate the need for restraints.) The order must be obtained
either during the emergency application of the restraint or
immediately (defined as without time interval) after the restraint has
been applied.
b.
If restraint continues to be clinically justified, continued use of
restraint must be authorized by the physician or other LIP. Restraint
orders must be renewed on a daily basis. A face-to-face physical
examination is required by the physician at least every calendar day
for non-violent restraint and every 24 hours for violent restraint to
determine the clinical justification for the continued use of restraints.
Restraint orders must be dated and timed when signed by physician,
and include: 1) criteria for release; 2) type of restraint used; 3) reason
for restraint; 4) and specify duration of restraint order.
Medical support restraint track
Maximum time for non-violent,
non- self- destructive restraint is a
calendar day based on physician
face to face assessment
2.
Violent restraint track
Maximum time for violent restraint:
4 hours ages 18 and up
2 hours ages 9-17
1 hour less than 9 years of age
May be renewed by phone up to 24
hours
Face to face assessment by physician
required at least every 24 hours with
phone contact every 4,2,1 hour for
renewal
Additional assessment by physician
or trained RN or PA required within
1 hour of order regardless of
removal of restraint/seclusion
If the ordering physician is not the attending physician, the attending
physician must be consulted as soon as possible. The attending physician
may have information regarding if the patient’s history significantly impacts
the use or selection of the restraint.
[Insert
Hospital
Logo]
[Insert Policy Manual Title]
Title:
RESTRAINT AND SECLUSION
3.
Restraint orders are never written on an “as needed” basis or as PRN orders
or standing orders. Trial releases are not permitted as the release of the
patient is considered as discontinuation of the restraint order. Therefore, to
allow the patient to again be restrained using the same order equals a PRN
restraint order.
a.
4.
C.
No.
CQ-4.004
Page:
4 of 9
Origination Date:
06-21-12;
03-01-12; 02-10-09; 04-28-06
Effective Date:
xx-xx-xx
Retires Policy Dated:
xx-xx-xx
Previous Versions Dated:
xx-xx-xx
Hospital Governing Board
Approval Date:
xx-xx-xx
Medical Staff Approval Date: xx-xx-xx
A temporary release that occurs for the purpose of caring for a
patient’s needs, i.e., toileting, feeding, and range of motion, is not
considered a discontinuation of the intervention.
If the need for restraint is based on a significant change in the patient’s
condition, the Registered Nurse must immediately notify the physician or
licensed independent practitioner.
Documentation
1.
Each episode of restraint use shall be documented in the patient’s medical
record, and shall include but not be limited to:
a.
Assessment and reassessment, including:


Significant changes in the patient’s condition that warranted
restraint use
Patient’s response to restraint
b.
Relevant orders for use of restraints, including least restrictive
intervention, time limit, clinical justification, type of restraint to be
used, and criteria for release.
c.
Results of patient monitoring will occur at regular intervals
according to the individual’s assessed needs but not to exceed 2
hours between intervals.
d.
Use of restraints must be addressed in the patient’s modified plan of
care.
e.
Discontinuation of restraint at earliest possible time.

Decision based on the determination that the medical need
for restraint is no longer present or that the patient’s needs
can be met with less restrictive methods.
[Insert
Hospital
Logo]
[Insert Policy Manual Title]
Title:
RESTRAINT AND SECLUSION
2.
Patient needs will be met during restraint use
a.
Restraint may not act as barrier to the provision of safe and
appropriate care, treatments, and other interventions to meet the
needs of the patient.
b.
The plan of care will not be compromised by the use of restraints and
shall include:







3.
No.
CQ-4.004
Page:
5 of 9
Origination Date:
06-21-12;
03-01-12; 02-10-09; 04-28-06
Effective Date:
xx-xx-xx
Retires Policy Dated:
xx-xx-xx
Previous Versions Dated:
xx-xx-xx
Hospital Governing Board
Approval Date:
xx-xx-xx
Medical Staff Approval Date: xx-xx-xx
Provision of nutritional needs
Provision of hydration needs
Provision of elimination needs
Provision of hygiene needs
Provision of exercise and range of motion
Provision of patient safety and comfort
Discuss restraint, when practical, with patient and family
around the time of use
Monitoring and Reassessment
a.
The restrained patient is assessed, monitored, and reassessed.
b.
Individual patient need and health status is used to establish the
frequency, nature, and extent of monitoring that is required by the
patient in restraints.
c.
Monitoring is accomplished by observation, direct face-to-face
interaction with the patient or related direct examination of the
patient by trained and competent staff.
d.
Appropriate interval for re-assessment is based on the patient needs,
condition, and type of restraint use.
Medical Support Restraint
Track
Real-time documentation of
assessment of restrained
patient status at a minimum of
every 2 hours
Violent Restraint Track
Continuous monitoring with real time
documentation of assessment of
restrained patient at least every 15
minutes
[Insert
Hospital
Logo]
[Insert Policy Manual Title]
Title:
RESTRAINT AND SECLUSION
e.
A patient in restraints is monitored at least every two hours or sooner
according to patient need. (Example: continuous face-to-face
monitoring may be needed when restraint leaves a patient
vulnerable.)
f.
Monitoring determines the following:




g.
D.
No.
CQ-4.004
Page:
6 of 9
Origination Date:
06-21-12;
03-01-12; 02-10-09; 04-28-06
Effective Date:
xx-xx-xx
Retires Policy Dated:
xx-xx-xx
Previous Versions Dated:
xx-xx-xx
Hospital Governing Board
Approval Date:
xx-xx-xx
Medical Staff Approval Date: xx-xx-xx
Patient’s physical and emotional well-being
Maintenance of patient’s right, dignity, and safety
Assessment of patient’s condition to determine if the current
restraint should be continued or if less restrictive methods
could be used or restraints could be discontinued
Safety of restraint application, removal or re-application
Assessment and Reassessment must include, but are not limited to:

Circulation (including vascular checks such as capillary refill,
temperature, and color of skin

Sensation

Level of distress and agitation

Behavior

Mental status

Cognitive functioning

Elimination needs

Patient safety and comfort, during and after restraint is
removed

Other criteria based on the type of intervention used and the
patient’s condition.
Death Reporting Requirement
The Hospital must report deaths associated with the use of restraint or seclusion.
Refer to Clinical Safety policy CQ-2.010 Sentinel Event Response and Reporting
for guidance on reporting of deaths which occur while the patient is in restraint or
seclusion, occur within 24 hours after the removal from restraint or occur within 1
week after use of restraint or seclusion and it is reasonable to assume that the cause
of death was directly or indirectly related to the restraint or seclusion.
1.
The Hospital will report the following information to CMS (amended per
July 16 COP changes to 482.13 Patient Rights) by telephone, facsimile, or
electronically, as determined by CMS, no later than the close of business on
[Insert
Hospital
Logo]
[Insert Policy Manual Title]
Title:
RESTRAINT AND SECLUSION
No.
CQ-4.004
Page:
7 of 9
Origination Date:
06-21-12;
03-01-12; 02-10-09; 04-28-06
Effective Date:
xx-xx-xx
Retires Policy Dated:
xx-xx-xx
Previous Versions Dated:
xx-xx-xx
Hospital Governing Board
Approval Date:
xx-xx-xx
Medical Staff Approval Date: xx-xx-xx
the next business day following knowledge of the patient’s death:




2.
E.
Each death that occurs while a patient is in restraint or seclusion
Each death that occurs within 24 hours after the patient has been
removed from restraint or seclusion.
Each death known to the hospital that occurs within 1 week after
restraint or seclusion where it is reasonable to assume that use of
restraint or placement in seclusion contributed directly or indirectly
to a patient’s death, regardless of the type(s) of restraint used on the
patient during this time. “Reasonable to assume” in this context
includes, but is not limited to, deaths related to restrictions of
movement for prolonged periods of time, or deaths related to chest
compression, restriction of breathing or asphyxiation.
The staff must document in the patient’s medical record the date and
time the death(s) was reported to CMS.
When no seclusion has been used and when the only restraints used on the
patient are those applied exclusively to the patient’s wrist(s), and which are
composed solely of soft, non-rigid, cloth-like materials, the hospital staff
must record in an internal log or other system, the following information:

Any death that occurs while a patient is in such restraints

Any death that occurs within 24 hours after a patient has been
removed from such restraints.

Entries into the internal log or other system must be documented as
follows:
o Each entry must be made not later than seven days after the date of
death of the patient;
o Each entry must document the patient’s name, date of birth, date of
death, name of attending physician or other licensed independent
practitioner who is responsible for the care of the patient, medical
record number, and primary diagnosis;
o The information must be made available in either written or
electronic form to CMS immediately upon request.
Responsible Person
The
[insert title]
is responsible for ensuring that all individuals adhere
to the requirements of this policy, that these procedures are implemented and
followed at Facility and that instances of non-compliance with this policy are
[Insert
Hospital
Logo]
[Insert Policy Manual Title]
Title:
RESTRAINT AND SECLUSION
No.
CQ-4.004
Page:
8 of 9
Origination Date:
06-21-12;
03-01-12; 02-10-09; 04-28-06
Effective Date:
xx-xx-xx
Retires Policy Dated:
xx-xx-xx
Previous Versions Dated:
xx-xx-xx
Hospital Governing Board
Approval Date:
xx-xx-xx
Medical Staff Approval Date: xx-xx-xx
reported to the
[insert title of senior individual with leadership/operational
oversight for the area]
.
F.
Auditing and Monitoring
The Hospital is responsible for monitoring performance improvement and
competency according to the requirements set out in Attachment B, Performance
Improvement and Competency. Quality Management will audit compliance to this
policy.
G.
Enforcement
All Hospital staff and Medical Staff Members whose responsibilities are affected
by this policy are expected to be familiar with the basic procedures and
responsibilities created by this policy. Failure to comply with this policy will be
subject to appropriate performance management pursuant to all applicable
policies and procedures, including the Medical Staff Bylaws, Rules and
Regulations.
VI.
REFERENCES:
- www.jointcommission.org, HAS Patient Care Standards: Restraint and Seclusion and Frequently
Asked Questions: Restraint and Seclusion
- Medicare Conditions of Participation for Hospitals, 42 CFR 482.13
- Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions
of Participation Final Rule Federal Register, 77 FR 29034
- www.apna.org, “Learning from each other: Success Stories and Ideas for Reducing Restraint and
Seclusion in Behavioral Health”
- Clinical Safety policy CQ-2.010 Sentinel Event Response and Reporting
VII.
ATTACHMENTS:
- Attachment A: Restraint Flowcharts
- Attachment B: Performance Improvement and Competency
- Attachment C: Definitions and Information Points
[Insert
Hospital
Logo]
[Insert Policy Manual Title]
Title:
RESTRAINT AND SECLUSION
No.
CQ-4.004
Page:
9 of 9
Origination Date:
06-21-12;
03-01-12; 02-10-09; 04-28-06
Effective Date:
xx-xx-xx
Retires Policy Dated:
xx-xx-xx
Previous Versions Dated:
xx-xx-xx
Hospital Governing Board
Approval Date:
xx-xx-xx
Medical Staff Approval Date: xx-xx-xx
- Attachment D: Special Considerations Associated with Special/Vulnerable Populations
Attachment A
CQ-4.004 Restraint and Seclusion
Page 1 of 2
Restraint Flowchart
06-21-12
Attachment A
CQ-4.004 Restraint and Seclusion
Page 2 of 2
Restraint Flowchart
06-21-12
Attachment B
CQ-4.004 Restraint and Seclusion
Page 1 of 3
Performance Improvement and Competency
The Governing Board, Medical Staff and Hospital leadership are responsible and accountable for
ensuring that quality and performance improvement efforts address the priority for improved care
and safety. This Hospital has established a priority for performance improvement activities that
focuses on the high risk area of restraint and seclusion. The Hospital collects data that measure the
performance of potentially high-risk processes such as restraint and seclusion.
Example: CNO or designee reviews daily all use of restraints and reports his/her
analysis through the Hospital’s performance improvement processes, including
reports to Medical Staff and Governing Board.
Medical Staff Roles and Responsibilities include the continuous assessment and improvement of the
quality of care and treatment. LIPs participate in measuring and assessing the use of restraint and
seclusion for all patients in the Hospital.
The Hospital must ensure that each patient’s right to be free from restraints is protected and must
take actions to comply with requirements through its Quality and Performance Improvement
activities. Hospital leadership will assess and monitor the use of restraint and seclusion, and
implement actions to ensure only medically necessary restraints are used. One suggested
methodology is to maintain a restraint and seclusion log.
1.
2.
Non-violent or non-self-destructive restraints
a.
Data regarding use of nonviolent or non-self-destructive restraints is
collected to assist the facility in measuring and assessing restraint use to
identify opportunities to introduce preventive strategies, alternatives to use,
and process improvements that reduce the risks associated with restraint use.
[Refer to Performance Improvement Plan for Restraint Reduction.]
b.
Data on all non-violent or non-self-destructive restraint episodes are
collected from and classified for all settings/units/locations by the following:
­ Patient identified (e.g., name, record number, account)
­ Shift
­ Staff who initiated the process
­ Date and time each episode was initiated
­ Day of the week each episode was initiated
­ Length of episode of restraint
­ Type of restraint use
­ Whether injuries were sustained by the patient staff
­ Age of the patient
­ Gender of the patient
Violent or self-destructive restraint or seclusion
Data regarding use of violent or self destructive restraint or seclusion is collected to
monitor and improve its performance of processes that involve risks. Data is used to
do the following:
03-01-12
Attachment B
CQ-4.004 Restraint and Seclusion
Page 2 of 3
a.
3.
Performance Improvement and Competency
Ascertain that restraint and seclusion are used only as emergency
intervention
b.
Identify opportunities for incrementally reducing the rate and increasing the
safety of restraint and seclusion use
c.
Identify any need to redesign care processes
(1)
Data on all violent or self destructive restraint and seclusion episodes
are collected from and classified for all settings/units/locations by the
following:
­ Patient identifier (e.g., name, record number, account)
­ Shift
­ Staff who initiated the process
­ Length of each episode
­ Date and time each episode was initiated
­ Day of the week each episode was initiated
­ Type of restraint used
­ Whether injuries were sustained by the patient or staff
­ Age of the patient
­ Gender of the patient
(2)
Particular attention shall be paid to the following:
­ Multiple instances of behavioral restraint or seclusion experienced
by a patient within a 12-hour time frame
­ Number of episodes per patient
­ Instances of restraint or seclusion that extend beyond 12
consecutive hours
­ Use of psychoactive medications as an alternative for or to enable
discontinuation of restraint or seclusion
Staff Training and Competency
a.
All staff who have direct patient care responsibilities and who are involved
with the application of restraint, implementation of seclusion; providing care
for a patient in restraint or seclusion, or with assessing and monitoring the
condition of the restrained or secluded patient must have ongoing education
training in the proper and safe use of restraints. This includes all staff that
have direct patient care responsibilities and any other individuals who may
be involved in the application of restraints (e.g., security guards). Staff must
have completed the training requirements outlined in this policy prior to their
involvement in seclusion or restraint episodes, as part of orientation, and
annually thereafter. Physicians must be educated regarding the restraint
policy and procedure and their role in caring for the restrained patient.
[DEFINE THE HOSPITAL’S TRAINING REQUIREMENTS FOR
PHYSICIAN AND OTHER LIPS AUTHORIZED TO ORDER
RESTRAINT AND SECLUSION. TRAINING SHOULD BE BASED
ON THE COMPETENCY LEVEL OF THE PHYSICIAN AND THE
03-01-12
Attachment B
CQ-4.004 Restraint and Seclusion
Page 3 of 3
Performance Improvement and Competency
NEEDS OF THE PATIENT POPULATIONS BEING SERVED BY
THAT PHYSICIAN. MEDICAL STAFF CREDENTIALING AND
PRIVILEGING FILES SHOULD REFLECT THE PHYSICIAN’S
REQUIRED TRAINING.]
b.
All staff that has direct patient contact must have education and training in
alternative methods for handling behavior, symptoms and situations that
may result in restraint or seclusion. This education and training must
identify techniques to identify staff and patient behaviors, events, and
environmental factors that:

May trigger circumstances that require the use of restraint or
seclusion

The use of non-physical intervention skills

Choosing the least restrictive intervention based on an individualized
assessment of the patient’s medical, or behavioral status or condition

The safe application and use of all types of restraint or seclusion used
in the Hospital, including training in how to recognize and respond to
signs of physical and psychological distress

Clinical identification of specific behavioral changes that indicate
that restraint or seclusion is no longer necessary

Monitoring the physical and psychological well-being of the patient
who is restrained or secluded, including but not limited to respiratory
and circulatory status, skin integrity, vital signs, and any special
requirements specified by Hospital policy associated with the 1-hour
face-to-face evaluation

c.
And the use of first aid techniques and certification in the use of
cardiopulmonary resuscitation, including required periodic
recertification.
The employee’s HR file must contain competency validation for safely
applying, monitoring, and removing restraints before the employee
participates in any use of restraint or seclusion. Demonstrated competence
should be done initially at orientation and annually thereafter. A list of
restraints that are approved for use in the facility is developed as guidance
for this competency validation. (Refer to Hospital’s Restraint and Seclusion
Staff Training and Competency Policy for a detailed listing of the
components of this training).
03-01-12
Attachment C
CQ-4.004 Restraint and Seclusion
Page 1 of 3
Definitions and Information Points
DEFINITIONS:
Physical Restraint
Holding the patient means physically holding a patient in a manner that restricts his/her movement
(this would include therapeutic holds) constitutes restraint for that patient. Holding a patient can be
just as restrictive and potentially dangerous as restraining methods using devices. Physically
holding a patient during a forced psychotropic (or other) medication procedure is considered
physical restraint.
Chemical Restraint
Is the inappropriate use of a sedating psychotropic drug to manage or control behavior. A
medication used to manage the patient’s behavior or restrict the patient’s freedom of movement that
is not considered a standard treatment or dosage for the patient’s condition is a chemical restraint.
Medication should not be used at any time as a restraint.
Example of a drug used inappropriately as a restraint:
A patient has Sundowner’s Syndrome. She gets out of bed in the evening and walks
around the unit. The unit’s staff find the patient’s behavior bothersome, and ask
the physician to order a high dose of a sedative to “knock out” the patient and keep
her in bed. The patient has no medical symptoms or conditions that indicate that
she needs a sedative
Example of a drug that is not used as a restraint:
A patient is in a detoxification program. He becomes violent and aggressive one
afternoon. A Nurse administers a PRN medication ordered by the patient’s
physician or LIP to address this outburst of specific behaviors. The use of the
medication enables the patient to better interact/function.
Side Rails
Rails on the sides of patient beds and stretchers. When all four side rails are raised in order to
restrain a patient, side rails are a restraint. When a patient is on a stretcher, recovering from
anesthesia, sedated, experiencing involuntary movement, or on certain types or therapeutic beds to
prevent the patient from falling out of the bed, side rails are not a restraint. The risk presented by
side rail use should be weighed against the risk presented by the patient’s behavior as ascertained
through individualized assessment. Clinical judgment determines whether or not the use of side
rails should be considered a restraint.
Seclusion
Seclusion is different from timeout. “Timeout” means the restriction of a patient for any period of
time to a designated area from which the patient is not physically prevented from leaving and for
the purpose of providing the patient an opportunity to regain self control. In “timeout”, the staff
and patient collaboratively determine when the patient has regained self control and is able to
return to the treatment milieu. In seclusion, this determination is made by the staff.
Attachment C
CQ-4.004 Restraint and Seclusion
Page 2 of 3
Definitions and Information Points
Voluntary Mechanical Support
A voluntary mechanical support used to achieve proper body position, balance, or alignment so as
to allow greater freedom of mobility than would be possible without the use of such support is not
considered a restraint. Examples would include surgical positioning, arm board during intravenous
administration, papoose boards for the insertion of pediatric intravenous devices, radiotherapy
procedures, protection of surgical and treatment sites in pediatric patients, helmets, back braces,
neck braces, and leg braces, orthopedically prescribed devices, surgical dressings or bandages.
Age or developmentally appropriate protective safety interventions
Age or developmentally appropriate protective safety interventions that a safety-conscious child
care provider outside a health care setting would utilize to protect an infant, toddler, or preschoolage child would not be considered restraint or seclusion. Example of these would be strollers, safety
belts, swing safety belts, high chair lap belts, raised crib rails, and crib covers.
Forensic and Correction Restrictions
Forensic and Correction Restrictions are defined as devices used by law enforcement officials to
restrain prisoners. The use of restrictive devices, such as handcuffs, applied and monitored by law
enforcement officials are not governed by restraint guidelines. However, restraint use related to
clinical care for individuals under forensic or correction restrictions will follow these restraint
guidelines. The forensic patient is the prisoner of the law enforcement officer, but the individual is
the patient of the hospital; therefore, the hospital is responsible for the provision of safe and
appropriate care.
INFORMATION POINTS:
Management of Violent or Self-Destructive Behavioral Restraint is the use of restraint for
demonstrated outburst of severely aggressive behavior that poses an imminent danger to the patient
or others. In such cases, the management of violent or self-destructive behavior restraint
requirements must be followed.
Management of Non-Violent or Non-Self-Destructive Restraints is the use of restraint to protect the
patient from harm and support medical healing. In such cases, the Management of Non-Violent or
Non-Self-Destructive Restraint requirements must be followed.
Setting is the location where the patient is being treated. The requirements for the use of both
management of violent or self-destructive behavior restraints and nonviolent or non-self-destructive
restraints are not specific to any treatment setting, but to the situation the restraint is being used to
address. A restraint to manage violent or self-destructive behavior must meet the requirement
whether it occurs on an acute medical and surgical unit, psychiatric unit, or rehabilitation unit. The
intent is to refer to a behavior rather than a setting or diagnosis.
Assessment
The use of restraints must be limited to clinically appropriate and adequately justified situations. A
comprehensive assessment for determining that not only the need for a restraint but also the
potential physical affects would include the following:
03-01-12
Attachment C
CQ-4.004 Restraint and Seclusion
Page 3 of 3
Definitions and Information Points
a. Potentially harmful behavior
b. History of behavior
c. Current behavior
d. Physical and cognitive status
e. Circumstances that led to consideration of restraint or seclusion use.
f. Current risk factors associated with observed behavior
g. Risk of restraint use versus benefits of the restraint to the patient
h. Patient/Family concepts/Feelings about Restraints
i. Determination of least restrictive intervention and rationale for selection
j. Consideration of less restrictive alternatives tried and/or failed in the past, including failure
of non-physical interventions (ineffective methods).
k. Physical status related to restraint usage that may include:
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
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Vital signs for relevance to the physical safety of the use of restraint
Nutritional and hydration needs
Circulation status
Range of motion status
Hygiene needs
Elimination needs
Other monitoring based on type of intervention used and the patient’s condition.
Opportunities to reduce the risk of slipping, tripping or falling.
l. Safety and well being after the restraint is removed
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CQ-4.004 Restraints and Seclusion
Page 1 of 3
Special Considerations Associated with Special/Vulnerable Populations
1. There are risks involved in any physical intervention. Therefore, risks should always be
considered when the danger presented by the patient’s behavior outweighs the risks of
physical intervention.
2. The initial assessment of each patient upon admission assists in obtaining information about
the patient that could help minimize the use of restraint or seclusion as well as reduce the
inherent risk to the physical safety and psychological well-being of the patient.
3. Patient with pre-disposing risk factors include, but are not limited to patients, with the
following:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
Pregnancy
Asthma
Smoker
Head or spinal injury
History of fracture
History of surgery
Deformity
Seizure disorder
Obesity
Geriatric
Children
Abuse – physical, emotional, sexual, rape
4. Restraining a patient in a supine position may predispose the patient to aspiration.
a. If the patient must be restrained in the supine position, ensure that the head is free to
rotate to the side, and when possible, the head of the bed is elevated to minimize the risk
of aspiration.
b. Have suction equipment accessible and ready for immediate use.
5. Restraining a patient in the prone position may predispose the patient to suffocation.
a. If the patient must be restrained in the prone position, ensure that the airway is
unobstructed at all times (for example, do not cover or “bury” the patient’s face). Also,
ensure that expanse of the patient’s lungs is not restricted by excessive pressure on the
patient’s back (special caution is required for children, elderly patients, and very obese
patients).
6. Restraining a patient in a room that is not under continuous observation by qualified staff
increases the risk of injury to the patient.
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CQ-4.004 Restraints and Seclusion
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Special Considerations Associated with Special/Vulnerable Populations
7. Equipment related factors may increase the risk of injury to patient:
a. Use of split side-rails without side-rail protectors
b. Use of a high-neck vest
c. Incorrect application of a restraining device monitor or alarm not working or not being
used when appropriate.
d. Monitor or alarm not working or not being used when appropriate.
8. Risk of bed-rail entrapment is increased for patients with any of the following:
a. Confusion or other cognitive impairment
b. Sedation
c. Restlessness
d. Lack of muscle control
e. Small physical size
9. Geriatric Patients
a. Increased risk of strangulation in vest restraints
b. Increased risk of bed-rail entrapment
c. Ensure airway is unobstructed at all times. Ensure there are no loose items around the
patient’s head such as bed linens, towels or any type of plastic linen protection.
d. Special consideration must be given to bowel and bladder function, skin integrity, and
risk of falls.
10. Patients at Risk for Self Harm or Suicide
a. Complete suicide risk assessment upon admission, and as defined in suicide risk
assessment policy.
b. Patients with identified suicide risk will have continuous observation.
c. Ensure safe care environment by detecting and securing contraband such as sharps,
matches, drugs, etc.
11. Cognitive Impairment
a. Because of increased risk of injury related to bed-rail entrapment and strangulation, it is
recommended that patients with significant cognitive impairment be constantly
monitored while in restraint.
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CQ-4.004 Restraints and Seclusion
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Special Considerations Associated with Special/Vulnerable Populations
12. Pediatric Patients
a. Ensure correct type and size of restraint is used specific to the size, weight, and
developmental age of the patient.
13. Drug Overdose (Drug Abuse)
a. Ensure safe care environment by detecting and securing contraband such as drugs,
alcohol matches, etc., including access from family and friends.
b. At risk for asphyxia due to sedation.
c. At risk for aspiration or strangulation due to vomiting
14. Patients with deformities, fractures, injury or physical limitations that preclude proper
application of restraining devices.
a. Assessment will include physical variances that could impact the proper application of
restraint device.
b. If the physical variances do not allow for the safe application of the restraint device, other
less restrictive interventions must be implemented to ensure the safety of the patient.
c. High vest and waist restraints will Not be used
15. Smokers
a. Ensure that all smoking materials are removed from patient’s access, including access
from family and friends.
b. Patient/family education regarding the risk associated with smoking while in restraints.
REFERENCES:

TJC Sentinel Event Alert: Preventing Restraint Deaths, Nov. 18, 1998

Learning from Each Other: Success Stories and Ideas for Reducing Restraint/Seclusion in
Behavioral Health; APNA/APA/NAPHS

Non-Violent Crisis Intervention Training Program, Crisis Prevention Institute, Inc.
TJC Sentinel Event alert: Bed rail entrapment deaths, Sept. 6, 2002
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