TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117
APPROVED: PAGE 1 of 13
EFFECTIVE DATE: 7/2008 REVISION DATE: 3/01/2010
Documentation / Related Documents
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. Restraint or seclusion may only
be used when less restrictive interventions have been determined to be ineffective to protect
the patient, other patients, or staff from harm. The least restrictive intervention must be used
first and then determined if a more restrictive environment, restraint, or seclusion will better
meet the needs of the patient.
Patients at risk for injury may need to be temporarily restrained. A physical restraint is any
device, garment, material, or object that restricts a person’s freedom of movement or
access to his or her body. The restraint must be clinically justified and a part of the
prescribed medical treatment and plan of care, and all other less restrictive measures
must be tried first.
The use of restraints has been associated with serious complications. The Food and Drug
Administration (FDA), which regulates restraints as medical devices and requires
manufacturer’s to label them “prescription only”, estimates that hundreds of restraint-
related injuries occur each year, approximately 100 of them resulting in patient death.
Most patient deaths have resulted from suffocation from a vest or jacket restraint. Numerous
institutions have stopped using vest restraints, including Bloomington Hospital. For these
reasons vest restraints will not be presented here.
Pressure ulcer formation, hypostatic pneumonia, constipation, incontinence, contractures,
and neurovascular impairment can result from the enforced immobility that results from using
restraints. Altered sensory perception and altered thought processes, such as delirium, may
also result. Humiliation, fear, anger, and a decreased sense of self-esteem may occur. For
this reason, a patient’s dignity will be maintained while any patient is restrained or secluded.
2. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117
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This may include visiting restriction of family, primarily on the Behavioral Health Units at
When the use of restraints is the only appropriate intervention to maintain the patients’ safety,
the patient should be informed that the restraint is temporary and protective, along with family
when applicable. As with other procedures, the nurse and all other staff must follow specific
institution guidelines when using restraints. Restraints or seclusion require a physician’s
order, which should specify the type of behavior or condition requiring restraint, the type of
restraint, and time limitations for restraint application. A face-to-face assessment by the
physician or other licensed independent practitioner or a registered nurse who has
been trained by established guidelines is required within one hour of initiation of
restraints for violent or self-destructive behavior. Orders should be renewed according to
Bloomington Hospital policy and based on reassessment and reevaluation of the restrained
Not all patients will be able to accept the use of restraints easily. Cultural values affect how
patient’s and family members perceive the use of restraints. The nurse assesses the
meaning of restraint to the patient and the family (when applicable). Nurse and family
collaboration can help with culturally sensitive care. Removing restraints when family
members are present can be an option if patient safety is not jeopardized.
A RESTRAINT IS:
The application of physical force to a patient with or without the patients’ permission to
restrict his or her freedom of movement. The physical force may be human,
mechanical devices, or a combination thereof.
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
A Restraint may be used in response to emergent, dangerous behavior; as an adjunct
to planned care; as a component of an approved protocol; or, in some cases, as part
of standard practice. Because a restraint may be necessary for certain patient’s, health
care organizations and providers need to be able to use restraints when essential to
protect patient’s from harming themselves, other patient’s, or staff. They also need to
be aware of the associated risks of both its’ use and nonuse.
Any drug or medication when it is used as a restriction to manage the patients’
behavior or restrict the patients’ freedom of movement and is not a standard treatment
or dosage for the patients’ condition.
A Restraint Does NOT INCLUDE:
The specific device used to restrain a patient does not in itself determine whether these
standards apply, it is the device’s intended use (such as physical restriction), its’
involuntary application, and/or the identified patient need that determines whether use of the
device triggers the application of these standards. This also does not include devices, such
3. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117
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as orthopedically prescribed devices, surgical dressings or bandages 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 bed, or to permit the patient
to participate in activities without the risk of physical harm.
These standards do not apply to the following:
Standard practices that include limitation of mobility or temporary immobilization
related to medical, dental, diagnostic, or surgical procedures and the related post-
procedure care processes (i.e. surgical positioning, intravenous arm boards,
radiotherapy procedures, protection of surgical and treatment sites in pediatric
Adaptive support in response to assessed patient need (i.e. postural support,
orthopedic appliances, table top chairs [geriatric/cardiac]).
Forensic and correction restrictions used for security (i.e. handcuffs)
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 or self-destructive behavior.
Alternatives to Restraints:
Non-physical techniques are always considered the preferred intervention. Such
interventions may include:
Redirecting the patient’s focus
Open visitation to elicit family help
Placing a pillow in the lap of the patient who is sitting
Involving Occupational/Recreational Therapy to structure patient time
Angled cushions for chairs
Arm sleeves (netting)
Allowing the patient to voluntarily cooperate
Getting patient out of bed and out of room (if applicable)
4. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117
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Assessment and Documentation for Restraints/Seclusions for Violent or Self Destructive
1. The Restraint/Seclusion Orders are to be filled out with the computer or written clinical
documentation placed in patient’s chart containing:
a. Initial reasoning for the restraint/seclusion, including all behaviors
b. The alternatives which were attempted first
c. The type of restraint initiated or if only the use of seclusion was needed.
2. Begin a Nursing Care Plan for the Restraint/Seclusion
3. Notations are to be made every 15 minutes for adults 18 years and older, 5 minutes
for adolescents and children 17 years and younger, and placed on a 1:1 with staff to
remain at arms length of patient at all times.
4. A time limit for verbal/written orders for patient’s in restraints/seclusion with Behavioral
a. 4 hours for adults (18 yrs and older)
b. 2 hours for children and adolescents (9-17 yrs)
c. 1 hour for patient’s under the age of 9 years.
5. Document any injury noted during the restraint or seclusion episode in patient’s chart.
6. Document physical and psychological status every 2 hours including:
c. Elimination needs
d. Capillary refill
e. Need for continuation of restraints/seclusion
f. Any significant changes in behaviors
g. Any significant changes with physical appearance or findings
h. Notify physician immediately if f or g have occurred
7. If patient remains in restraints up to 2 hours reposition and continue repositioning
every 2 hours.
8. Assess and document patient’s readiness for discontinuation of restraints/seclusion at
least every 2 hours including:
a. Patient’s awareness of the rationale for the restraint or seclusion
and the behavior criteria for discontinuation.
5. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117
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9. Restraint or Seclusion is discontinued as soon as the patient meets his or her behavior
10. Patient’s dignity and privacy is to be maintained at all times to the best of the situation
11. Once patient removed from restraints or seclusion a debriefing is to be completed with
input from staff and patient. The debriefing form is to be given to the Clinical Director.
Documentation that the debriefing form was completed and all other appropriate
documentation is placed in the patients’ chart.
Use of Restraint or Seclusion in the Management of Violent or Self Destructive Behavior
1. Restraints 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.
2. When restraints or seclusion are initiated it is preferred the physician be notified and give
the order for restraints/seclusion prior to the application. If the behaviors or situation do not
permit the notification prior to placing the patient in restraints/seclusion staff may initiate and
then notify the physician and receive the verbal or written order as soon as possible, not to
exceed 1 hour.
3. In the utilization of restraints or seclusion on the Behavioral Health inpatient units it is the
responsibility of the attending psychiatrist or on call psychiatrist to give the written or verbal
orders. These orders are to be given prior to application, during the emergency application, or
as soon as the situation permits, not to exceed 1 hour. Written or verbal orders for
restraint/seclusion for violent or self destructive behavior with primary behavioral health
needs are time limited to:
a. Every 4 hours for adults age 18 years and older
b. Every 2 hours for children and adolescents age 9-17 years
c. Every 1 hour for patient’s under age 9 years
4. The psychiatrist, or specifically trained Registered Nurse (RN), is to do a visual
assessment of the patient within one (1) hour of the initiation and application of the
restraints/seclusion to evaluate:
a. The patients’ immediate situation
b. The patients’ reaction to the intervention
c. The patients’ medical and behavioral condition
d. The need to continue or terminate the restraint or seclusion
If the face to face assessment is completed by the specifically trained RN they must
consult with the psychiatrist as soon as possible after the evaluation.
5. The psychiatrist will document all above findings in the patients’ chart under the progress
notes. The specifically trained RN will document his/her assessment using the Bloomington
6. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117
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Hospital restraint assessment form in the SHARQ format (situation, history, assessment,
recommendations, questions) and place in the patients’ chart under the progress notes.
6. If the patient has not met the behavioral criteria for discontinuation of restraints or
seclusion for patients with a primary behavioral health need the attending or on call
psychiatrist is to do a face to face full assessment and document in patients’ chart:
a. Every 8 hours for adults 18 years and older
b. Every 4 hours for children and adolescents 9-17 years
c. Every 1 hour for children under age 9 years
The Simultaneous use of Restraint and Seclusion for Violent or Self Destructive
Behavior is not utilized in the Behavioral Health Units at Bloomington Hospital.
Seclusion Only for Violent or Self Destructive Behavior the patient is to be 1:1 for
the first hour and observed by audio and video by staff continuously after the first hour
on the inpatient psychiatric units.
The staff person observing the 1:1 is to be trained in Non-Violent Crisis Intervention
and must be in close proximity, or within arms length of the patient and available to
Seclusion can only be performed in a security room designed for this purpose. (Crisis
Care Unit at Bloomington Hospital)
Any type of restraint requires a 1:1 (face to face) on the inpatient psychiatric units.
Any patient with 4 way and/or locked restraints requires a 1:1 (face to face) on all units
that are appropriate for the patient including:
Intensive Care Units
Behavioral Health Units
The application of force to physically hold a patient, in order to administer a medication
against the patient’s wishes, is considered a restraint. The patient has a right to be free of
restraint, and also has a right to refuse medications, unless a court has ordered medication
treatment. A court order for medication treatment only removes the patient’s right to refuse
the medication. Additionally, in accordance with State Law, some patient’s may be medicated
against their will in certain emergency circumstances. However, in both of these
circumstances, health care staff is expected to use the least restrictive method of
administering the medication to avoid or reduce the use of force, when possible. The use of
force in order to medicate a patient, as with other restraint, must have a physician’s order
prior to the application of the restraint (use of force). If physical holding for forced medication
7. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117
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is necessary with a violent patient, the 1-hour face-to-face evaluation requirement would also
All restraints used on the Behavioral Health Units are considered Behavioral.
In an event that 4 way and/ or locked restraints are required on any other units
not mentioned above must have a 1:1 who is a trained Behavioral Health staff
person for monitoring and maintaining appropriate documentation at all times.
Staff Training Requirements for the Application and Monitoring of Behavioral
Health Patient’s with Primary Behavioral Health Needs in Restraints/Seclusion
The person applying restraints/seclusion must have received education, training, and
demonstrated knowledge based on the specific needs of the patient population
requiring the application, monitoring and documentation of Behavioral Restraints and
Techniques to identify behaviors, events, and environmental factors that may
trigger circumstances that require the use of a restraint or seclusion
Use of nonphysical 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 restraints used at Bloomington
Hospital including training on how to recognize and respond to signs of physical
and psychological distress (i.e. positional asphyxia)
Clinical identification of specific behavioral changes that indicate the restraints
are no longer necessary
Monitoring the physical and psychological well-being of the patient who is
restrained or secluded
Use of first aid techniques (i.e. management of minor scrapes/bleeding), CPR
certification, and monitoring vital signs
Initiation, Application, Monitoring and Documentation of restraints/seclusion
Recognizing nutritional/hydration needs
Checking circulation/capillary refill
Range of Motion
Hygiene and elimination needs
Maintain annual competency in all of the above
Face to Face Evaluation:
In addition to the restraint and seclusion education and training, designated RN’s will
complete the following training
Non-Violent Crisis Intervention
Advanced assessment training presented by a psychiatrist
8. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117
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Management of delirium and dementia
Designated RN’s includes: Behavioral Health Charge Nurses, Critical
Care/Cardiovascular Charge Nurses, Pediatric Charge Nurses, Rapid Response RN,
and all Patient Care Director’s.
All physicians caring for patients at Bloomington Hospital will receive training in
regards to any updates or revisions made to the policies and orders for Behavioral and
Medical Restraints and Behavioral Seclusion.
Monitoring and Reporting Requirements of Behavioral or Medical Restraints and
The use of Behavioral or Medical Restraints and/or Seclusion will be reported to the Patient
Care Director including patient name and room number. The collection of data regarding the
use of restraints and seclusion will be utilized in reducing the risk of restraints and the use of
Hospitals must report deaths associated with the use of restraints or seclusion according to
the following CMS guidelines:
Each death that occurs while the patient is either in Medical or Behavioral Restraints
Each death that occurs within 24 hours after the patient has been removed from
Medical or Behavioral Restraints or Seclusion
Each death known to the hospital that occurs within 1 week after Medical or Behavioral
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
Bloomington Hospital Patient Care Directors will be responsible for reporting the above
circumstances to the CMS no later than the close of business the next day following
knowledge of the patient’s death
The Patient Care Director will document in the patient’s medical record the date and
time the death was reported to the CMS
If any patient remains in Behavioral Restraints or Seclusion for a period of 8 hours, or
experiences two or more separate episodes of restraint and/or seclusion of any duration
within 8 hours the Clinical Leaders (i.e. Clinical Director, Psychiatrist) are to be notified to do
Assess whether additional resources are needed to facilitate discontinuation of
restraint and/ or seclusion
Minimize recurrent instances of restraint and/or seclusion
Thereafter, the Clinical Leaders are notified every 8 hours if either of the above conditions
9. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117
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Patient Assessment and Preparation
1. Determine patient’s need for restraint if other less restrictive measures fail
to prevent interruption of therapy or injury to self or others. Confer with
psychiatrist or primary health care provider.
2. Assess patient’s behavior, such as confusion, disorientation, agitation,
restlessness, combativeness, or inability to follow directions.
3. Review institution policies regarding restraints. Check physician’s order for
purpose of restraint and type, location, time and duration of restraint.
Determine whether signed consent for use of restraint is needed.
4. Review manufacturer’s instructions for restraint application before entering
patient’s room. Determine the most appropriate restraint.
5. Inspect area where restraint is to be placed. Note if there is any nearby
tubing, jewelry, or devices. Assess condition of skin, sensation, and joint
range of motion, if applicable, of underlying area on which restraint is to be
1. Identify patient by checking armband and having patient state name, if applicable.
2. Approach patient in a calm, confident manner. Explain what the plan of staff is and
what staff will be doing.
3. Gather equipment, and perform hand hygiene.
1. Provide privacy and maintain patient’s dignity, as the situation permits. Position and
drape patient as needed.
Rationale: Prevents lowering of patient’s self-esteem
2. Adjust bed to proper height, and lower side rails. (Crisis Care beds are non-adjustable
and will be utilized appropriately)
Rationale: Allows nurse and staff to use proper body mechanics
and prevent injury
3. Maintain patient’s comfort and in correct anatomic position.
Rationale: Prevents contractures and neurovascular impairment
4. Pad skin and bony prominences (as necessary) that will be under the restraint.
Rationale: Reduces friction and pressure from restraint on skin and
5. Apply appropriate size restraint and refer to manufacturer’s directions.
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a. Extremity (ankle or wrist) restraint: Restraint designed to immobilize one or all
extremities. Commercially available limb restraints are composed of sheepskin
or foam padding. Limb restraint is wrapped around wrist or ankle with soft part
toward skin and secured snugly in place with Velcro straps and/or locks.
Rationale: Maintains immobilization of extremity to prevent
patient injury from fall or accidental removal of therapeutic
device (i.e. IV tubing, foley catheter). Tight application may
interfere with circulation.
Patient with wrist and ankle restraints is at risk for aspiration if placed in a
supine position. Place patient in lateral position rather than supine.
6. Attach restraint straps to bed frame and to an area that does not cause the restraint to
tighten when head of bed is raised or lowered. (movable part of the bed). Do not
attach to side rails. In the use of soft wrist restraints the straps may be attached to
chair frame for patient in a chair or wheelchair.
Rationale: Patient may be injured if restraint is secured to side rail
And it is lowered.
7. Secure restraints with a quick-release tie.
Rationale: Allows for quick release in emergency.
8. Insert two fingers under secured restraint.
Rationale: Checking for constriction prevents neurovascular injury.
A tight restraint may cause constriction and impede circulation.
9. Restraints should be removed at least every 2 hours. If patient is violent or
noncompliant, remove one restraint at a time and/or have staff assistance while
Rationale: Provides opportunity to change patient’s position,
perform full range of motion, toileting, and exercise; and
provide food or fluids.
A violent or aggressive patient should not be left unattended while restraints are
10. Secure call light or intercom system within reach. (Patient’s in Behavioral Restraints
will have staff with them at all times).
Rationale: Allows patient, family, or caregiver to obtain assistance
Restraints restrict movement; making patient’s unable to perform their activities of
daily living (ADLs) without assistance. Providing food/fluids and assisting with
toileting and other activities is essential.
11. Leave bed or chair with wheels locked. (Crisis Care beds are bolted to floor). Bed
should be in the lowest position.
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Rationale: Locked wheels prevent bed or chair from moving if
patient attempts to get out. If patient falls when bed is in lowest
position, chances of injury is reduced.
12. Perform hand hygiene.
Rationale: Reduces transmission of microorganisms.
1. Evaluate proper placement of restraint, skin integrity, pulses, temperature, color, and
sensation of the restrained body part at least every 2 hours or sooner, according to
need and Bloomington Hospital policy.
Rationale: Frequent assessments prevent complications, such as
suffocation, skin breakdown, and impaired circulation
2. Inspect patient for any injury, including all hazards of immobility, while restraints are in
use. Also inspect patient during routine removal of restraint.
Rationale: Patient should be free of injury and not exhibit any
signs of complications from immobility.
3. Observe IV catheters, urinary catheters, and drainage tubes to determine that they are
positioned correctly and that therapy remains uninterrupted.
Rationale: Reinsertion can be uncomfortable and can increase risk
of infection or interrupt therapy.
4. Review Behavioral Restraints every 2 hours, with documentation every 15 minutes,
and every 2 hours in nursing notes. A face to face assessment by a physician for Medical
Restraints is every 24 hours with a new written order for continuation of the restraints. A
face to face assessment by a psychiatrist for Behavioral Restraints every 8 hours with a
new written order for continuation of the restraints. (See Bloomington Hospital’s specific
Rationale: The intent is to discontinue restraints at the earliest
Patient remains free from injury
Patients therapy is uninterrupted
Patients self-esteem and dignity are maintained
Patient experiences impaired skin integrity related to improper or prolonged use of
Patient has altered neurovascular status of an extremity, such as cyanosis, pallor, and
coldness of skin, or complains of tingling, pain, or numbness
Patient exhibits increased confusion and disorientation
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Patient experiences shortness of breath and impaired air exchange
Patient releases restraint and experiences a fall or other traumatic injury
Patient has psychological distress
Patient has death
Thoroughly explain the use of restraints
In the use of restraints for Violent or Self Destructive Behaviors on the
Behavioral Health Units patients family will not be allowed to visit to maintain
patients dignity and safety
Patient has extensive debriefing after discontinuation of restraints and/or
Documentation/ Related Documents
Record nursing interventions employed to ensure patients safety before
use of restraints
Record patients behaviors before restraints were applied, level of
orientation, and patients or family members understanding of the
purpose of the restraints. (If applicable)
In nurses’ notes or on restraint flow sheet, record type and location of
restraint applied, time restraint was applied, and specific assessments
related to oxygenation, skin integrity, musculoskeletal system, and
peripheral vascular integrity an
Record patients behavior after restraints were applied, times patient was
assessed while restraints were on and findings, attempts to use
alternatives to restraint and patients response, times restraint was
released (temporarily and permanently), and patients response when
restraints were removed
The use of restraints should be limited to clinically appropriate and adequately justified
situations after all appropriate alternatives have been used. Restraints are only used
on children to restrict movement when patient’s are at risk of injuring themselves or
When a child needs to be restrained for a procedure, it is best that the person applying
the restraint not be the child’s parent or guardian
A mummy restraint is a safe, efficient, short-term method to restrain a small child or
infant for examination or treatment. Open blanket and fold one corner toward the
center, place child on blanket with shoulders at fold and feet toward opposite corner.
With child’s right arm straight down against body, pull right side of blanket firmly
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across right shoulder and chest and secure it beneath left side of body. Place left arm
straight against body, and bring left side of blanket across shoulder and chest and lock
it beneath child’s body on right side. Fold lower corner and bring it over body and trunk
or fasten it securely with safety pins.
Advanced age is not in itself an indication for use of restraints. Promoting functional
restoration by performing individual assessment of risk factors, determining if a need is
not being met, orienting patient as needed, modifying the environment, teaching
muscle strengthening exercises, and meeting older patient’s needs in ADLs will help
prevent falls and other traumatic injuries.
Center for Medicare and Medicaid Services