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Columbus Regional Hospital
Patient Care Policy/Procedure Manual
Policy/Procedure Code: PC-R-1 00007 r18-0
Effective Date:
10-1-1996
Revised
Reviewed
Date/Initials
Date/Initials
1/1995 – JM/SF
1/1996 – JM/ MR/
6/1993
6/1996 – JM/SR
KR/SR/SF
6/1997 – RG
9/1997 – CS
1/1998 – JMM
3/29/1999 – JM/JF
2/2000 – JMM
3/2000 – JMM
4/2000 – JMM
4/26/2000 – KMH
4/27/2000 – RG
5/31/2000 – RG
9/15/2000 – RG, JM
9/19/2000 - RC
5-18-2001 - JMM
9-18-01 - JMM
9/03 JF
10/18/06 NPC JF 12/15/06
01/29/07 JF
4/9/07 Kathy Brock
3/7/08 JF
9/9/09 JFisher
Subject:
Restraint – For non-violent, non-self destructive behavior for medical surgical care and/or restraint for
violent self-destructive behavior.
Medical Surgical Policy:
All patients have the right to be free from physical or mental abuse, and corporal punishment. All
patients have the right to be free from restraint or seclusion, of any form, imposed as a means of
coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to
ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued
at the earliest possible time, regardless of the length of time identified in the order. .
Columbus Regional Hospital's Mission is to improve the health and well-being of the people we serve.
Restraint management poses an inherent risk to the physical safety and psychological well being of the
patient and staff. Restraints will only be used in an emergency for patients who are treated at Columbus
Regional Hospital’s acute care units or Emergency Department exhibiting violent or self-destructive
behavior or symptoms in which there is an imminent risk of safety of an individual by physically
harming himself/herself or others. Columbus Regional Hospital employees continually explore ways to
prevent and reduce the use of restraints, and strive to eliminate the use of restraints through effective
performance improvement initiatives
A patient whose current behavior puts him/her at high risk for harming self or others may be restrained
by physical or mechanical methods or seclusion after less restrictive interventions have proven
Copy to:
Author:
Dr. S Franz, M. Ritter, S. Frazita
J. Maupin, S. Robbins, K. Reeves
Restraint Advisor Committee
Approved: Nursing Practice Council
Restraint Advisor Council
Thomas Sonderman, MD
Chief Medical Officer
Cheri Goll
VP/CNO
10/5/09
9/22/09
12-09
Date
10/05/09
Date
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ineffective to protect the patient or staff from harm. . (Assessed needs are not necessarily based on the
prior history of the patient). Staff members are trained to minimize the use and provide restraint
management safely.
Education is provided to the patient/family/support system when possible regarding the need for
initiation of restraint, monitoring mechanisms, reassessment of patient needs and potential for removal.
Purpose:
1. To establish guidelines for the safe, effective use of restraints in accordance with state, and
regulatory requirements.
2. To ensure the protection of the rights, dignity, physical and psychological well being of
individuals requiring restraint.
3. To protect the health and safety of patient and others.
4. To promote optimal therapy via a treatment plan which supports the prescribed medical regimen
while identifying patient needs and interventions necessary to expedite a quick and safe removal
of restraints.
Responsibilities/Competencies (Knowledge, skill, I.P.):
Physician)
1.
2.
3.
4.
5.
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The use of restraint or seclusion must be in accordance with the order of a physician or other
licensed independent practitioner who is responsible for the care of the patient and authorized
to order restraint or seclusion by hospital policy.
Orders for restraint or seclusion must never be written as a standing order or on an as needed
basis (PRN)
The attending physician must be consulted as soon as possible if the attending physician did
not order the restraint or seclusion.
Each order for restraint or seclusion used for the management of violent or self-destructive
behavior that jeopardizes the immediate physical safety of the patient, a staff member, or
others 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 9-17 years of age
 1 hour for children under 9 years of age
After 24 hours, before writing a new order for the use of restraint or seclusion for the
management of violent or self-destructive behavior, a physician or other licensed
independent practitioner who is responsible for the care of the patient and is authorized to
order restraint must see and assess the patient. The physician should review with the staff
the physical and psychological status of the individual and identifies behavioral health
symptomatology. The physician will determine whether restraint or seclusion should be
continued and supplies staff with guidance or works with the patient in identifying ways to
help the individual regain control in order for the restraint to be discontinued.
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6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
The condition of a patient who is restrained or secluded must be monitored by a physician,
other licensed independent practitioner or trained staff that have completed the training
criteria as identified by hospital policy and at the interval identified by hospital policy. At a
minimum the physicians and other licensed independent practitioner authorized to order
restraint and seclusion must have a working knowledge of hospital policy.
When restraint or seclusion is used for the management of violent or self-destructive
behavior that jeopardizes the immediate physical safety of the patient, a staff member or
others, the patient must be seen face-to-face within one hour after the initiation of the
intervention by a physician or other licensed independent practitioner or a Registered Nurse
or physician assistant who has been trained to evaluate:
 The patients immediate situation
 The patient’s reaction to the intervention
 The patient’s behavioral and medical condition
 The need to continue or terminate the restraint or seclusion
If the face to face evaluation of a patient with violent or self destructive behavior is done by a
trained registered nurse or physician assistant, they must consult the attending physician or
other licensed independent practitioner who is responsible for the care of the patient as soon
as possible after the 1-hour face to face evaluation.
A qualified registered nurse or other qualified, trained staff members may initiate the use of
restraints before an order is obtained from the licensed independent practitioner
Each order for restraint used to ensure the physical safety of the non-violent or non selfdestructive patient will have physician authorization within 12 hours.
The initial order must be time limited, not to exceed 24 hours for restraint.
For the patient with non-violent non-self-destructive behavior, the physician must conduct a
face-to-face examination within 24 hours of initiation of restraint and document the
examination in the medical record.
Every calendar day, every patient must be seen by the physician for a face-to-face evaluation
of the clinical condition of the patient and write a new timed and dated order if restraints
continue to be needed for the nonviolent or non-self-destructive patient.
The physician written order shall include the justification for restraints and shall specify
restraint type and time limits.
Physician will participate in review of restraint use and more effective options for
management at least every calendar day.
Medical staff involvement in Process Improvement activities will be via participation in the
MEC.
Competency demonstrates a working knowledge of hospital policy regarding the use of
restraint and seclusion. This will be accomplished at the time of appointment or
reappointment of medical staff.
RN:
The effects and consequences of restraint use and immobilization can include: Aspiration pneumonia,
elimination problems, skin integrity, strangulation, and/or feeling humiliated and demoralized. All
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patients when restrained should be considered vulnerable. Certain patient populations where this may
be more evident include but are not limited to:
A. Cognitively impaired individuals, those with mental status changes
B. Physically impaired, the frail, pediatric, the elderly, prone positioned patients
C. Sensory impaired individuals.
D. Those with developmental disability
E. Any history of sexual or physical abuse that would place the individual at
greater psychological risk
1. Physical restraints are not to be applied to the following: paralyzed, fractured or circulatory
impaired extremities, over grafts, hemodialysis fistula sites, and intravenous access sites or
during seizures.
2. Physical restraints are to be secured to an immovable part of a bed or chair frame closest to
the desired anatomical position and using quick release ties. The patients calls light or
alternative call methods and frequently used items are to be placed close.
3. Four point restraints shall be used only under emergency circumstances.
4. Use Restraint Alternatives to decrease identified patient behaviors and document
effectiveness. Based on patient assessed needs, make decisions about alternatives and least
restrictive methods.
5. After alternatives have failed, assess the need for restraint application.
6. Notify physician of risk factors, patient behavior, and restraint alternatives attempted/failed.
In an emergency situation, an R.N. may assess and authorize restraint interventions if patient
poses immediate danger to self or others. A physician’s order must be obtained within 12
hours for a non-violent non-self destructive patient and must include time limit, type of
restraint, and purpose of restraint.
7. Notify and obtains an order (telephone or written) from the attending physician or Licensed
Independent practitioner with-in one hour of initiation for a restraint applied as a result of
violent or self-destructive behavior. Consult with the physician or the LIP about the
individual’s physical and psychological condition.
8. Make an effort to discuss the issue of restraint for safety reasons with the patient and the
family the time of its use. Include the reason for restraint, type of restraint, alternatives
attempted and continued assessment for readiness of removal.
9. Notify patient’s family promptly of the initiation of seclusion in the event the individual has
agreed to have the family kept informed regarding his/her care and the family agrees to be
notified.
10. Direct the safe application and removal of restraints and positioning of the patient by
qualified staff. Initiate, monitor, evaluate and discontinue (including early release) the
restraints as patient behavior dictates and based on assessed needs. .
11. Protect the patient and preserve the patient’s rights, dignity and well being during use.
12. Reassess for continued use, correct application, circulation sensation/joint mobility, skin
integrity, respiratory status, behavior, patients right and dignity.
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13. Provide patient care needs: nutrition, hydration, skin, elimination, range of motion, physical
and emotional well-being, patient rights dignity and safety. (See Special Instructions:
Intervention).
14. Notify physician or the licensed independent practitioner of clinical assessment and
justification of continued use of restraints and obtain order renewal each calendar day or as
appropriate for violent or self-destructive behavior
15. In the case of a child or adolescent patient, notify parent/guardian of initiation of restraint. If
the parent or guardian voice objection, notify the physician.
16. Direct trained staff in the proper use of restraints to initiate monitor and discontinue restraint
use.
17. Direct the change in the staffing plan.
18. Notifies leadership if restraints or seclusion used for violent or self-destructive behavior.
19. Documents according to policy
Managers:
1.
2.
3.
4.
5.
Document staff competency beginning with orientation.
Update staff competency with annual review of process improvement opportunities,
activities, and identified needs.
Develop staffing matrix around staff’s ability/need, census and special needs of patient
population and patient acuity.
Review and when necessary redesign the patient care process associated with restraint use.
Identify membership of nursing staff to serve on the Restraint Advisory Council for process
improvement activities.
Protective services:
1.
May assist the staff and registered nurse in the application of restraint.
Other Trained Staff:
1.
2.
May assist in initiating restraints, monitoring patient and providing comfort needs.
Document competency and keep in unit competency/education file and update annually.
Special Instruction
Before ordering restraint, consideration must be given to any potential medical (including psychiatric)
contraindications, e.g., history of physical or sexual abuse.
1.
2.
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Restraint may be used as an intervention when less restrictive, less limiting measures have been
attempted and failed and it has been determined the patient is a danger to self and/or others.
The physician's initial time limited order is limited to 24 hours for nonviolent non-selfdestructive adults. The order form is specific for the “Initial Order” Documentation includes the
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specific behavior which constitutes the danger to self or others and behavioral criteria. This
order is dated, timed, and signed by the physician. After the original order expires, the patient is
reassessed by a face-to-face interview with the physician and a new order is written if restraint
is to be continued on the “Re-order” form. Documentation of the face-to-face evaluation will be
in the patient record. If a violent or self-destructive behavior patient is no longer in restraint
when an original verbal order expires, the physician conducts an in-person evaluation of the
individual with in 24 hours of the initiation of restraint or seclusion
3.
4.
Only a physician or a competent registered nurse may initiate restraint in an emergency situation.
When restraint is the appropriate intervention, it is to be used for the shortest period of time
necessary to enable the individual to effectively cope with his/her environment or situation.
5. Individuals placed in restraint must have an observable environment that safeguards their
personal dignity and well-being.
6. Only the minimum physical force necessary may be used to implement a restraint and only
accepted nonviolent crisis intervention/prevention techniques may be utilized.
7. Written modification to the patient's plan of care occurs with any restraint usage.
8. All use of restraints is reported to the Manager, and follow-up will be taken to correct
unwarranted utilization.
9. Data of restraint utilization will be collected and analyzed to identify opportunities for
improvement.
10. Each instance of restraint is documented in the patient restraint flow sheet/medical record.
Equipment:
Selected restraint, i.e. soft limb, leather/nylon limb, Freedom Splint, tied mitt.
Central stores maintains a stock of disposable limb restraints and Freedom Splints. Additional
products needed may be ordered through the purchasing department. Consult with them for available
products. The Restraint advisory council will review new product information and consult with
individual needs.
Procedure:
1.
Application:
a.
A competent registered nurse, physician or licensed independent practitioner shall
direct, evaluate and document the initial application of restraining devices
b. The registered nurse will notify the physician that the patient is requiring restraint.
c.
Make an effort to discuss use of restraints when practical with the patient and /or family
around the time of its use.
d.
Prior to use, read and follow the manufacturer's directions for use:
1) Select the type of restraint appropriate to patient's condition
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2)
e.
f.
g.
h.
i.
Secure restraints designed for use in bed to the bed frame, never to the mattress
or side rails. If the bed is adjustable, secure restraints to parts of the bed that
move with patient
Have adequate number of staff to assist with procedure.
Maintain patient in good body alignment. If a patient must be restrained in the prone
position, ensure that the airway is unobstructed at all times. Ensure that expansion of
the patient's lungs is not restricted by excessive pressure.
Place patient's call device within reach of the restrained patient if personnel are not
within visual/auditory range
If non-locking restraints are used, the straps must be secured to the bed frame by quick
release knots.
Remove all smoking materials from the room. Educate the family to provide no
smoking materials.
2.
Monitoring:
The condition of the patient who is restrained or secluded must be monitored by a physician
or licensed independent practitioner or trained staff that have completed training criteria. .
For the non violent and the non-self-destructive patients, trained staff will complete a face-toface interaction at least every two-hour, monitor the patient’s condition and document in the
patients medical record. Monitoring is accomplished by observation, interaction with the
patients or related direct examination of the patient. It is recommended that patients be
monitored at least every two hours on the even hours except for special cause-initial
application of restraint, response to restraint or at transfer.
a. Visual safety checks –Staff will make visual safety checks, which will include
circulation, mobility, and skin integrity, at least every two hours for the acute patient
to confirm that patient is safe and to provide comfort measures as needed.
b. Circulation/Mobility/Sensation/Skin Integrity
1) Circulation - monitor extremity distal to limb restrained for neurovascular
abnormalities - include skin color, temperature, sensation and capillary refill.
2) Joint Mobility and Sensation - monitor patient ability to move extremity and
feel sensations while limb restraint applied.
3) Skin Integrity - monitor skin beneath applied restraint for abrasions or
bruising.
c. Monitoring considers the physical and emotional well being of the patient; patient
rights, dignity, and safety; whether less restrictive methods are possible; changes in
behavior to initiate early removal of restraints; and whether the restraint has been
appropriately applied, removed or re-applied.
d. Develop staffing matrix around staff’s ability/need, census and special needs of patient
population (acuity, medical needs,)
3.
Documentation will include: (*, ** see next page)
a.
Preventative strategies
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b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
Evidence/type of restraint alternatives attempted
*If in use; least restrictive restraint methods tried
Patient and family education and participation that occurred if possible
**Clinical justification/criteria for use of restraint-description of patient
behavior/condition or symptoms
Physician order for restraint and the type of restraint
Time/date patient placed in restraint
Attempts at early release of restraints.
Type of restraint
Nurse initiating the restraint
Face-to-face evaluation by physician – initial and daily
Care provided every two hours
Measures taken to protect the rights, dignity, and well being of the patient.
Evidence of change in Plan of Care.
*Less restrictive alternatives used prior to restraint application (includes, but not limited to):
1) Medication- not with intent to sedate or chemically restrain
2) Active listening
3) Family visits
4) Bed check system
5) Appropriate lighting
6) Verbal De-escalation /encourage patient to express concerns
7) Reduce environmental stimuli
8) Diversional activities
9) Sitter
10) Positioning
11) Exercise
12) Nonrestrictive appliances/devices
13) Unsecured mittens
**Criteria for restraint (included, not limited to):
1) To ensure physicial safety
2) Potential for removal of lines/tubes
3) Other patient specific.
Staff will document in the non-violent non-self-destructive patients medical record, every two
hours on the even hour:
a. Nutrition - offer meals and snacks TID and PRN while patient is awake
b. Hydration - offer fluids while patient is awake
c. Hygiene- provide for hygiene needs; offer assistance with bathing, oral care, and
grooming
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d. Elimination - offer bathroom, BSC, bedpan, or urinal access
e. Comfort- provide for comfort including positioning and environmental comfort (room
temperature, lighting, etc.).
f. Ambulate- assist patient in ambulating as patient is able and or provide ROM
g. Circulation/Mobility/Sensation/Skin-During monitoring, restraints may be removed for
circulation, skin care, exercise, bathroom access.
h. Rights and dignity and safety
i. If patient is combative/violent/agitated, at least 2 staff members are present for this
process and instead of full restraint removal simultaneously; one extremity at a time is
released and reapplied. Document if patient is too agitated to cooperate with restraint
removal.
4.
Interventions:
Staff will document in the patients medical record, every two hours on the even hour:
j. Nutrition - offer meals and snacks TID and PRN while patient is awake
k. Hydration - offer fluids while patient is awake
l. Hygiene- provide for hygiene needs; offer assistance with bathing, oral care, and
grooming
m. Elimination - offer bathroom, Bedside commode, bedpan, or urinal access
n. Comfort- provide for comfort including positioning and environmental comfort (room
temperature, lighting, etc.).
o. Ambulate- assist patient in ambulating as patient is able and or provide ROM
p. Circulation/Mobility/Sensation/Skin-During monitoring, restraints may be removed for
circulation, skin care, exercise, bathroom access.
q. Rights and dignity and safety
r. If patient is combative/violent/agitated, at least 2 staff members are present for this
process and instead of full restraint removal simultaneously; one extremity at a time is
released and reapplied. Document if patient is too agitated to cooperate with restraint
removal.
Assessment, Reassessment, Monitoring and Care of violent or self-destructive behavior patient in
restraint or seclusion
1. Monitoring:
Simultaneous restraint and seclusion is only permitted if the patient is continually monitored
face to face by an assigned, trained staff member or by trained staff using both video and audio
equipment and this monitoring must be in close proximity to the patient
An assigned staff member who is trained and competent with monitoring patients in restraints
accomplishes monitoring through continuous in-person observation
If the patient is in a physical hold, a second staff person is assigned to observe the patient
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2. Assessment
1. The individual in restraints are to be assessed and assisted every 15 minutes. The purpose
of these assessments are as follows:
a. To assess if the appropriate type of restraint is employed.
b. To assess signs of any injury associated with the application of restraint.
c. To assist with nutrition and hydration.
d. To check circulation and provide range of motion.
e. To assess vital signs.
f. To provide hygiene and elimination.
g. To assess physical and psychological status and comfort.
h. To provide assistance to the individual in meeting the behavior criteria for the
discontinuation of restraint.
i. To ensure the individual’s rights and dignity, physical and emotional safety.
2. A staff member who is trained and competent will complete this assessment and assist the
patient with care needs at the initiation of restraint and every 15 minutes. This
assessment includes, as appropriate to the type of restraint employed:
a. Signs of any injury associated with the application of restraint or seclusion;
b. Nutrition/hydration;
c. Circulation and range of motion in the extremities;
d. Vital signs;
e. Hygiene and elimination;
f. Physical and psychological status and comfort; and
g. Readiness for discontinuation of restraint or seclusion.
5.
3. Staff provides assistance to individuals in meeting behavior criteria for the discontinuation
of restraint or seclusion.
All assessment, monitoring and observations will be documented every 15 minutes on the
Restraint Flow Sheet.
When restraint and seclusion are used simultaneously there must be documentation in the
patient’s medical record of the following:
1) The one-hour face-to-face medical and behavioral evaluation if the restraint or
seclusion is used to manage violent or self-destructive behavior.
2) A description of the patient’s behavior and the intervention used
3) Alternatives or other less restrictive interventions attempted (as applicable)
4) The patients condition or symptoms that warranted the use of the restraint or seclusion
and
5) The patient’s response to; the intervention used, including the rational for continued
use of the intervention.
Discontinuation/Early release of Restraints:
a.
Restraint or seclusion must be discontinued at the earliest possible time, regardless of
the length of time identified in the order. .
b. Trial releases may be attempted to determine if patient behavior has changed to a lower
risk level.
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c.
d.
If patient behavior re-escalates to a risk level meeting criteria for restraint use, a new
restraint order must be obtained.
The violent or self destructive behavior restraint will be discontinued when criteria for
release are met. In determining whether release criteria are met, staff must assess
whether the patient has demonstrated an ongoing ability to maintain control. Some
examples of release criteria are the following:
 An individuals ability to contract for safety
 Whether an individual is oriented to the environment
 Cessation of verbal or physical threats
 Documentation that behavior criteria were discussed
Patient and Family Education
Patient and family when practical are educated on the use of restraint. Patient and family education
includes:
1.
An explanation of the patient's behavior that may cause restraint use;
2.
An explanation of how restraints may be used to maintain needed therapies;
3.
A discussion of the alternatives available to the use of restraints;
4.
Ongoing assessment for readiness of removal of restraints
5.
The removal of smoking materials.
6.
Possible patient and family participation in the care that could limit or halt restraint use; and
7.
The patient's preferences should be incorporated whenever possible.
8.
Before the patient decides to request or refuse the use of restraint or seclusion, the patient
must be informed of the risks associated with refusing the use of restraint.
DEFINITIONS:
In its broadest context, Restraint is any manual method, physical 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 or a drug or medication when it 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. . A restraint does not include devices, such as orthopedically prescribed devices, surgical
dressings or bandages protective helmets, or other methods that involve the physical holding of a
patient for the purpose of conducting routine physical examinations or tests, or to protect the patient
from falling out of a bed, or to permit the patient to participate in activities without the risk of physical
harm (this does not include physical escort)
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 management of violent or selfdestructive behavior. Restraint or seclusion may only be used when less restrictive interventions have
been determined to be ineffective to protect the patient a staff member or others from harm. The type
or technique of restraint or seclusion used must be the least restrictive intervention will be effective to
protect the patient, a staff member, or others from harm. The use of restraint or seclusion must be in
accordance with written modification to the patient’s plan of care and implemented in accordance with
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safe and appropriate restraint and seclusion techniques as determined by hospital policy. Seclusion for
Med/Surg violent or self-destructive behavior will take place in the Emergency Department. There are
no rooms meeting criteria for seclusion on the medical surgical units.
Emergency - A situation in which it is immediately necessary to restrain or seclude a patient to
prevent: (a) imminent probable death or substantial bodily harm to the patient because the patient is
threatening or attempting to commit suicide or self mutilation; or (b) imminent physical or emotional
harm to others because of threats, or acts the patient makes or commits against others, or if preventive,
de-escalative, or verbal techniques have proven ineffective at diffusing the potential for injury. These
situations may include aggressive acts by the individual, including serious incidences of shoving or
grabbing others over their objections and/or significant property destruction.
1.
Restraint Episode – The number of hours from time of initiation of restraint to time of
removal of restraint for the same behavior
2.
Mechanical Restraint - The application of a mechanical device restricting the free
movement of the whole or a portion of an individual’s body in order to control physical
activity.
3.
Personal Restraint - The application of physical force to restrict the free movement of the
whole or a portion of an individual’s body in order to control physical activity.
4.
Physical restraint - Any manual method, physical or mechanical device, material or
equipment attached or adjacent to the patient's body that he or she cannot easily remove that
restricts freedom of movement or normal access to one's body. This includes supportive or
protective devices used as a safety measure to prevent falls or injury.
5.
Protective Devices - Restraints used to prevent involuntary self-injury to permit wounds to
heal or to maintain the integrity of the medical interventions (oxygen, IV Fluids, catheters,
etc.).
6.
Vests are not currently stocked at CRH because of infrequent use. Vests of the right style and
size can be ordered through the Purchasing Department.
7.
Sheets may not be used as a restraint.
8.
For the purpose of this policy, the following items are not considered involuntary restraints
and do not require an individual restraint order:
 Restraint use that is associated with medical, dental, diagnostic or surgical procedures
and is based on standard practice for the procedure and related post procedure care
processes( for example, surgical positioning, intravenous arm boards, radiotherapy
procedures, protection of surgical and treatment sites in pediatric patients). Such standard
practice may or may not be described in procedure or practice descriptions.
 Restraint device that is used to meet the assessed needs of a patient who requires
adaptive support (for example, postural support, orthopedic appliances) or medical
protective devices (for example helmets, tabletop chairs, bed rails). Such use is always
based on the assessed needs of the individual patient. Periodic reassessment assures that
the restraint continues to meet an identified patient need.
 Therapeutic holding or comforting of children or time-out when the person to whom it
is applied is physically prevented from leaving a room for 15 minutes or less, and when
its use is consistent with the behavior management standards.
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
9.
10.
11.
12.
Forensic and correction restrictions used for security purposes. However, restraint use
related to the clinical care of an individual under forensic or correction restrictions
would require restraint orders.
 A side rail guideline has been developed.
 Psychopharmacologic drugs used to modify behavior, considered chemical restraints, do
not apply under this policy.
Alzheimer patients are considered to be within the medical diagnoses.
Competent Registered Nurse is a registered nurse who completes the competency-training
program for the use of restraints.
Chemical Restraint - The use of any chemical, including pharmaceutical, through topical
application, oral administration, injection, or other means, for purposes of controlling
behavior or to restrict the patient's freedom of movement and is not a standard treatment for
the patient's medical or psychiatric condition.
CPI - The department’s approved risk management curriculum for minimizing the likelihood
of aggressive behaviors and managing their occurrences by using the least restrictive and least
intrusive interventions. (Crisis Intervention/de-escalation techniques)
Staff Education and training:
The patient has the right to safe implementation of restraint or seclusion by trained staff. Before
performing any of the actions specified below staff must be trained on orientation and on a yearly basis
and be able to demonstrate competency in:
1. Application of restraints
2. Implementation of seclusion
3. Monitoring
4. Assessment
5. Providing care for a patient in restraint or seclusion
Training Content;
1.
The hospital will require appropriate staff to have education, training, and
demonstrated knowledge based on the specific needs of the patient population in at
least the following:
a.
Techniques to identify staff and patient behaviors, events, and environmental
factors that may trigger circumstances that require the use of a restraint or
seclusion
b.
The use of nonphysical intervention skills
c.
Choosing the least restrictive intervention based on an individualized assessment
of the patient’s medical or behavioral status or condition
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d.
The safe application and use of all types of restraint used in the hospital
including training in how to recognize and respond to signs of physical and
psychological distress (for example positional asphyxia)
e.
Clinical identification of specific behavioral changes that indicate that restraint
or seclusion is no longer necessary
f.
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 special requirements specified by hospital
policy associate with the one hour face-to-face evaluation.
g.
The use of first aid techniques and certification in the use of cardiopulmonary
resuscitation, including periodic recertification.
Trainer requirements:
a.
Individuals providing staff training must be qualified as evidenced by education,
training, and experience in techniques used to address patient’s behaviors.
Training documentation:
a. The hospital will document in the staff personnel records that the training and
demonstration of competency were successfully completed at orientation and yearly
Process Improvement Plan
Restraint has the potential to produce serious consequences such as physical or psychological
harm, loss of dignity, violation of patient right and even death. By PROCESS IMPROVEMENT,
Columbus Regional Hospital continuously explores ways to decrease restraint use through
effective preventive strategies or use of alternatives.
1.
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Nurse Manager or designee reviews all charts of patients restrained in Med/Surg, Mental
Health and ED. Nurse manager in CCU reviews 10 charts per quarter
 Reason for Restraint
 Alternative attempted
 Patient and family notified/educated/participated in reasons for restraint.
 Type of restraint.
 Physician order written, name of physician
 PRN orders
 Initiation date and time.
 Restraint discontinued date and time.
 Total hours in restraint.
 Bedside documentation completed every 2 hours.
 Nurse initiating the restraint.
 Early release attempted
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2.
Enter date for each episode into Midas for tracking to establish trend data. This data is
forwarded to the Restraint Advisory Council.
 Every restraint episode on Med Surg and ED will be entered in Midas
 Enter Midas data on each episode only one time, which is at the time the restraint is
removed. Start date and removal of restraint will be an absolutely necessary data entry
in Midas
 It is important that someone is available to enter data on a daily basis when the manager
is not present or the manager needs to delegate data entry
Retrospectively, the manager of each unit reviews measurement data for their unit quarterly
for stabilization of processes.
The Restraint Advisory Council reviews measurement data regarding restraint management
quarterly for process improvement opportunities.
Process improvement opportunities are initiated to monitor improvement efforts
As changes in regulatory guidelines occur, staff education is planned and implemented based
upon process improvement evaluation, chart review and Midas Entrries
3.
4.
5.
6.
DEATH REPORTING REQUIREMENTS (see attachment A)
Hospitals must report deaths associated with the use of seclusion or restraint. The hospital must
report the following information to the CMS:
1) Each death that occurs while a patient is in restraint or seclusion
2) Each death that occurs within 24 hours after the patient has been removed for
restraint or seclusion
3) Each death known to the hospital that occurs with in one 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. : Reasonable to
assume” in this context includes, but is not limited to deaths related to restriction
of movement for prolonged periods of time or death related to chest
compression, restriction of breathing or asphyxiation
These deaths must be reported to CMS by telephone no later than the close of business the next
business day following knowledge of the patient’s death.
Staff must document in the patients medical record the date and time the death was reported to
CMS
References/Supporting Data:





Center for Study of Psychiatry and Psychology
Fall Prevention
Indiana Healthcare Consent Statutes
Regulatory Requirements for Restraints
National Alliance for the Mentally Ill.
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








National Institute of Health.
Perry, A. & Potter, P., Clinical nursing skills and techniques;
Potter, P. & Perry, A., Fundamentals of nursing: Concepts, process and practice;
Side-rail Guidelines Policy
The Mental Health Legal Advisors Committee
USDA Food and Drug Administration
Fall Prevention (See Section F, PC-F 00001)
Restraint and Seclusion (Mental Health) (Refer to Mental Health Policy & Procedure Manual)
Federal Register- Department of Health and Human Services- CMS Updates Effective Jan 8th,
2007
Attachments:
Attachment A: Guideline for Reporting Deaths Associated with Restraint or Seclusion to CMS
(Centers for Medicare and Medicaid Services)
Attachment A
Guideline for Reporting Deaths Associated with Restraint or Seclusion to CMS
(Centers for Medicare and Medicaid Services)
Guideline for Reporting Deaths Associated with Restraint or Seclusion to CMS (Centers for Medicare and
Medicaid Services)
Hospitals must report deaths associated with the use of restraint or seclusion. Following is a step-bystep process.
For any patient (any patient type such as ED, Clinic, Observation, Inpatient, Rehabilitation, Mental
Health) that dies:
1. Review medical record to determine any of the following:
a. Did the death occur while the patient was in restraint or seclusion?
b. Did the death occur within 24 hours after the patient has been removed from restraint or
seclusion?
c. Did the death occur within one week after restraint or seclusion used and it is reasonable
to assume that the use of restraint or placement in seclusion contributed directly or
indirectly to the patient’s death?
d. Was the hospital informed of a patient’s death that occurred within one week after
restraint or seclusion used and it is reasonable to assume that the use of restraint or
placement in seclusion contributed directly or indirectly to the patient’s death?
IF YES TO ANY OF THE ABOVE CONTACT ONE OF THE FOLLOWING INDIVIDUALS
2. If death in ED, inform the Manager of the Emergency Department or his/her designee.
3. If death in the ICU, inform the Manager of ICU or his/her designee.
4. All other deaths contact the Nursing Administrative Coordinator.
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THESE INDIVIDUALS WILL
5. Report the death to CMS by telephone no later than close of business the next business day
following knowledge of the patient’s death.
TO REPORT THE DEATH TO CMS
6. Complete the Hospital Restraint/Seclusion Death Report Worksheet.
7. Call CMS Regional Office Contact listed on worksheet and provide all the necessary
information.
8. Complete Form NUR-766 and attach patient label if available or place patient’s name, date of
birth, Medical Record Number and Account Number or date of discharge on form and send to
Health Information to be scanned into Chartmaxx. (CMS requires that documentation exists
in the medical record the date and time the death was reported to CMS.)
Chicago Regional Office
Centers for Medicare and Medicaid Services
233 North Michigan Avenue, Suite 600
Chicago, IL 60601-5519
Phone: 312-886-6432
Fax: 312-353-0252
Internet: www.CMS.gov/RegionalOffices/06_RO5.asp
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