Accreditation & Regulatory Journal
March 2023

CIHQ-ARS Blog

Restraints Part II – Restraints to Manage Violent/Self-Destructive Behavior and Seclusion

By: Robin Ruthford
This is the second part of a two-part article on the use of restraints and seclusion. This article will focus on the definition of a chemical restraint, definition of seclusion, as well as ordering, monitoring, documentation, and the training and education requirements for restraints and seclusion to manage violent/self-destructive behavior.
Each patient has the right to receive care in a safe setting. The type of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, staff members, or others from harm.
Definition of a chemical restraint and definition of seclusion
A chemical restraint is a drug or medication that 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. Medications that are used to treat a patient’s medical or psychiatric condition and are within the standard dosage would not be considered a chemical restraint. Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent/self-destructive behavior.
Ordering restraints to manage violent/self-destructive behavior or seclusion
Hospital policy along with state regulation determines the categories of licensing practitioners (LP) that may order restraints and seclusion. The order for restraints or seclusion must be obtained prior to the initiation of the intervention. In an emergency, however, the application of the restraint or seclusion may occur at the same time or before obtaining an order, but the order must be obtained within a few minutes of the initiation of the restraint or seclusion. Although State law may have more restrictive time limits, each order for restraint or seclusion used for the management of violent/self-destructive behavior has maximum time limits based on age, and may only be renewed in accordance with the following limits for up to a total of 24 hours:
  • 4 hours for adults 18 years of age or older
  • 2 hours for children and adolescents 9 to 17 years of age
  • 1 hour for children under 9 years of age
Restraints or seclusion should be discontinued at the earliest possible time, regardless of the length of time identified in the order. At the end of each timeframe, if it has been determined that restraints or seclusion to manage violent/self-destructive behavior need to continue, another order is required. PRN orders are not allowed, and each new episode of restraint or seclusion requires a new order. After 24-hours (or as specified by State law) an LP must see and assess the patient before issuing a new order. If the LP who ordered the restraint or seclusion was not the patient’s attending physician, the patient’s attending physician must be notified as soon as possible as defined by hospital policy.
Face-to-Face Evaluation
When a restraint or seclusion is used for the management of violent/self-destructive behavior, the patient must be seen in person within one hour after the initiation of the intervention by a LP or registered nurse who has been trained to conduct a face-to-face evaluation. A telephone call or the use of telemedicine is not permitted for this evaluation. The purpose of the face-to face evaluation is to complete a comprehensive review of the patient’s condition to determine if other factors, such as drug or medication interactions, electrolyte imbalances, hypoxia, sepsis, etc., are contributing to the patient’s violent or self-destructive behavior. If a patient’s violent or self-destructive behavior resolves and the restraint or seclusion is discontinued before the practitioner arrives to perform the one-hour face-to-face evaluation, the practitioner is still required to evaluate the patient within one hour of the initiation of the intervention.
During the one-hour face-to-face evaluation, the following must be evaluated:
  • The patient's immediate situation
  • The patient's reaction to the intervention
  • The patient's medical and behavioral condition to determine if other factors are contributing to the patient’s violent or self-destructive behavior
    • Review of systems
    • Behavioral assessment
    • Review of history, drugs and medications, recent lab results, etc.
  • The need to continue or terminate the restraint or seclusion
If a trained RN conducts the face-to-face evaluation, the RN must consult the attending physician or other LP responsible for the patient’s care as soon as possible (as defined by hospital policy) after the completion of the evaluation. This consultation should include, at a minimum, a discussion of the findings of the one hour face-to-face, the need for other interventions or treatments, and the need to continue or discontinue the use of restraint or seclusion.
Simultaneous use of restraint and seclusion
When the simultaneous use of restraint and seclusion is used, the patient must be continually (ongoing without interruption) monitored either face-to-face by a trained staff member or by using both video and audio equipment that is in close proximity to the patient.
Assessment and monitoring of patients
Ongoing assessment and monitoring of the patient’s condition by trained staff is crucial for prevention of patient injury as well as ensuring that the use of restraint or seclusion is discontinued at the earliest possible time. Hospital policy should guide staff in determining the appropriate frequency of monitoring and assessment, and assessment content based on the individual needs of the patient, the patient’s condition, and the type of restraint or seclusion used. The hospital is responsible for providing the level of monitoring and frequency of reassessment that will protect the patient’s safety. This may include respiratory and circulatory status, skin integrity, vital signs, mental status, level of distress and agitation, and neurological evaluations. In addition, hospital policy should address the timeframe for offering general care needs such as fluids and nourishment, toileting/elimination, range of motion, and systematic release of the restrained limb. Hospitals have the flexibility in determining which staff perform the patient assessments and monitoring in accordance with their scope of practice and State law.
Training and education
The training and education required for physicians, other LPs, and staff was discussed in Part I. In addition, an RN who conducts the one-hour face-to-face evaluation will need to be trained to conduct a physical and behavioral assessment of the patient.
What to expect during a survey?
During a survey, surveyors will review medical records to determine if the use of restraints or seclusion to manage violent/self-destructive behavior is consistent with hospital policies and procedures, as well as CMS requirements. This will include reviewing the following:
  • Orders from an LP
  • Notification of the use of restraints to the attending physician if the attending physician did not enter the initial order
  • Description of the patient's behavior and the intervention(s) used
  • Alternatives or other less restrictive interventions attempted (as applicable)
  • The patient's condition or symptom(s) that warranted the use of the restraint or seclusion
  • One-hour face-to-face evaluation
  • The patient's response to the intervention(s) used
  • Documentation that supports the continued need for restraint
  • Ongoing assessment and monitoring of the patient’s condition
  • Written modification to patient’s plan of care within a timeframe specified by hospital policy.
  • LP and staff personnel files for required training and education
In conclusion, there are many CMS regulations related to the use of restraints and seclusion to manage violent/self-destructive behavior.
References
Centers for Medicare and Medicaid Services, (2020). State Operations Manual, Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Retrieved from www.cms.gov.
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One of the most common restraint questions asked by a hospital during survey; "Are hand mitts considered restraint?" The answer is "it depends"!!
The first step is to determine what type of hand mitts you will place on the patient and how you will utilize them. There are several types of hand mitts that would not be considered a restraint. However, pinning or attaching those hand mitts to the bed or using a wrist restraint in addition with the hand mitts would meet the definition of a restraint by CMS. Therefore, the requirements would apply, and hospitals would need to follow the regulatory requirements for restraints.
Another example, if the mitts are applied so tightly that the patient’s hands or fingers are immobilized, or the hand mitts are so bulky they restrict the patient’s ability to use their hands, these too would meet the definition of restraints and the CMS requirement would apply.
For the sake of this discussion, let's say that the patient was placed in hand mitts because they were picking at their dressings which may potentially cause an increase chance to develop a wound infection. The patient still has the ability to move their fingers to eat and could also remove the hand mitts if needed. This situation would not be considered a restraint.
However, if the patient continuously removed the hand mitts, still having the ability to pick at their dressing and you tie them to the bed to prevent a potential hospital acquired infection, this then would be considered a restraint and the requirement would apply. Additionally, if you decided to change the hand mitts to bulky mitts and the patient is not able to use their hands or fingers freely, this too shall be considered a restraint.
Remember: CMS states that all patients have the right to be free from restraints, of any form, and not be used as a means of coercion, discipline, convenience, or retaliation by staff. Restraints may only be used to ensure the immediate physical safety of the patient, a staff member, or others, and must be discontinued at the earliest possible time.
  • Patients have a right to be free from restraint and seclusion
  • All forms of restraint should be used as a last resort
  • Restraint and seclusion must be based on orders from the physician
  • The patient must be monitored closely to prevent adverse outcomes
Just a few alternatives you may want to think of before applying hand mitts to your patient:
  • Re-orientation
  • Limit setting
  • Increased observation and monitoring
  • Use of a sitter
  • Change in the patient’s physical environment
  • Review and modification of medication regimens
The use of a hand mitt as a restraint intervention should be reflected in the patient’s plan of care or treatment plan based on an assessment and evaluation of the patient. The plan of care or treatment plan should be reviewed and updated in writing within 24 hours following the initiation of restraint.
Keep in mind that CMS does not name each device or describe every situation in their definition of physical restraint. It does define a restraint as a device that can be used to immobilize or reduce the ability of the patient to move his or her arms, legs, body, or head freely; it promotes looking at each situation on a case-by-case basis. This will help your staff develop the best plan of care for each individual patient when planning what type of hand mitt will be used for the safety of the patient and to protect the integrity of lines, dressings, and tubes.
References
CMS Conditions of Participation for Acute Care Hospitals, §482.13(e)(1)(i)(C)