Approved Date:08/28/2015 / EffectiveDate:TBD / Next ReviewDate:
08/01/2018
Document NumberP-NS-1063.6 / Document Type:Policy / Page 1 of12
Approved: DocumentControlCommittee, / Supersedes: v.5 PATIENT CARE -Restraints
1.Policy: All patients have the right to be free from physical or mental abuse, andcorporalpunishment. All patients have the right to be free from restraint of any form, imposedasa convenience, or retaliation by staff. Restraint may only be imposed to ensuretheimmediate physical safety of the patient, a staff member, or others and mustbediscontinued at the earliest possibletime.
2.Definitions
a.Non-Violent Restraint/Medicalis a medical restraint used for behavior driven byamedical condition. The patient is attempting to remove lines, tube,surgicaldressing or otherwise interfering with essential medical treatment. (Example:Thepatient whose confusion is due to a medical condition; this patient has nocontrolover thisbehavior).
b.Violent Restraint/Behavioralis used for those violent and destructive behaviors overwhichthe patient should have control. The patient exhibits behavior that jeopardizestheimmediate physical safety of the patient or others. (Example: The patient whohitsor threatens to hit staff in an effort tointimidate).
c.Restraint is any manual method, physical or mechanical device, material,orequipment that immobilizes or reduces the ability of a patient to move his orherarms, legs, body, or head freely; or a drug or medication when it is used asarestriction to manage the patient’s behavior or restrict the patient’s freedomofmovement and is not standard treatment or dosage for the patient’scondition.
d.Seclusion is the involuntary confinement of a violent patient alone in a roomorarea from which the patient is physically prevented fromleaving.
e.Restraint/Seclusion Episodebegins when restraints are initiated and ends when restraints are discontinued regardless of the number of minutes, hours or days the restraints arein use.
3.Exclusions: The following are, by definition, also not considered restraint andarespecifically excluded from thispolicy:
a.A voluntary mechanical support used to achieve proper body position, balance,oralignment so as to allow greater freedom of mobility than would bepossiblewithout the use of suchsupport.
Site: / Title: PATIENT CARE -RestraintsApproved Date:06/05/2015 / EffectiveDate:06/05/2015 / Next ReviewDate:
06/05/2018
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Approved: DocumentControlCommittee / Supersedes: v.5 PATIENT CARE -Restraints
b.Standard practices that include limitation of mobility or temporaryimmobilizationduring medical, dental, diagnostic procedures, or surgical positioning andrelated post-procedure care processes when such practice is considered an inherentpartof theprocedure.
c.Helmets
d.Patients restrained by law enforcement or other legalauthorities.
e.The use of side rails to assist with patient safety, unless the use is such thattheside rails prevent mobility (e.g. all four side rails up). (Side rails are a restraintifthe side rails reduce the ability of a patient tomove.)
f.Medication (including PRN) used as a standard part of a patient’s treatmentplanprovided the following criteriamet:
i.The medication is used within the pharmaceutical parameters approvedbyFood and Drug Administration (FDA) and the manufacturer fortheindications it is manufactured and labeled to address, includinglisteddosageparameter.
ii.The use of the medication follows national practice standardsestablishedor recognized by the medical community and/or professionalmedicalassociation ororganization.
iii.The use of medication to treat a specific patient’s clinical conditionisbased on the patient’s symptoms, overall clinical situation, and onthephysician’s or designee’s knowledge of that patient’s expected andactualresponse to themedication.
4.A restraint does not include devices, such as orthopedic prescribeddevices,surgical dressings or bandages, protective helmets, or other methods thatinvolvethe physical holding of a patient for the purpose of conducting routinephysicalexamination or test, or to protect the patient from falling out of bed, or topermitthe patient to participate in activities without the risk of physical harm andcaninclude age or developmentally appropriate protective safety interventions thatasafety conscious childcare provider outside a hospital would use to protectaninfant orchild.
5.Limitations and Criteria for Use of Restraint: The use of restraint is limited tothosesituations for which there is adequate and appropriate clinicaljustification.
a.Physicians, Physician Assistants, Nurse Practitioners, and other qualifiedlicensedpractitioners (QLP) are allowed to order restraints and to conduct a physicalandpsychological assessment of the patient. The order should be obtained prior totheinitiation of restraints. Restraint orders written by Physician Assistants mustbeco-signed by aphysician.
b.An RN trained in restraint use may discontinuerestraints.
c.If the patient’s physician did not initiate the order, they must be consulted assoonas reasonably possible. If the patient’s physician is unavailableand
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Approved: DocumentControlCommittee, / Supersedes: v.5 PATIENT CARE -Restraints
another QLP is covering for them, the covering QLP is considered thepatient’sphysician.
d.The use of restraint is based on the assessed needs of the patient. Restraintmayonly be used when less restrictive interventions have been determined tobeineffective to protect the patient, a staff member, or others fromharm.
e.The use of restraint occurs only after alternatives to such use havebeenconsidered and/or attempted as appropriate. Such alternatives may include, butarenot necessarily limitedto:
i.Re-orientation
ii.De-escalation
iii.Increased observation andmonitoring
iv.Use of asitter
v.Change in the patient’s physicalenvironment
vi.Review and modification of medicationregimens
f.The use of restraint must be in accordance with the written modification tothepatient’s Plan of Care; and implemented in accordance with safe andappropriaterestrainttechniques.
g.The least restrictive, safe and effective method of restraint is to be used. Thetypeor technique used must be the least restrictive intervention that will be effectivetoprotect the patient or others fromharm.
h.Restraint use should be discontinued when there is no longer adequateandappropriate justification for continued use and before an orderexpires.
i.An assessment by the QLP should include a physical assessment toidentifymedical problems that may be causing behavior changes in the patients.Theremay be instances when the assessment might occur after initiation ofrestraint.
5.Prohibitions to Use of Restraint The use of restraint for the following reasons isstrictlyprohibited:
a.Coercion, discipline, convenience, or staffretaliation.
b.Solely on the patient’s history of dangerous behavior, ifany.
c.Risk of Restraint Use The use of restraint has the potential to produceserious consequences such as physical and psychological harm, and even death. Thehospitalwill take risk factors into account when assessing the need for; selecting the typeofand determining the patient care needs relative torestraint.
6.Reporting of deaths of patients in restraint All deaths should be reported toHouseSupervisor. The hospital will report required deaths associated with the use of restraint totheCenter for Medicare Services (CMS) as appropriate. Reporting may also occur tootherexternal agencies as required by state law and /or organization policy. The following willbereported to House Supervisor:
a.Each death that occurs while a patient is inrestraint.
Printed documents are considereduncontrolled.
Printed copies are for reference only. Please refer to the electronic copy for the latestversion.
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06/05/2018
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Approved: DocumentControlCommittee, / Supersedes: v.5 PATIENT CARE -Restraints
b.Each death that occurs within 24 hours after the patient has been removedfromrestraints.
c.Each death known to the hospital that occurs within 7 days after restraint where itis reasonable to assume that use of restraint contributed directly or indirectly tothepatient death. ‘‘Reasonable to assume” in this context includes, but is not limitedto,deaths related to restrictions of movement for prolonged periods of time, ordeathrelated to chest compression, restriction of breathing orasphyxiation.
d.A log referencing each death will be maintained and updated by RiskManagement.Each death referenced as above must be placed on an internal log by. Deathsarereported to CMS no later than close of next business day of patient’sdeath.
e.Documentation will be placed in the patient’s medical record reflecting the dateandtime the death was reported to CMS and the time entry was made into the log.Allentries into the internal log must be completed within 7 days of the patient’sdeath.
f.Exception to CMS reporting requirement: The following deaths are not reportedtoCMS. When no seclusion has been used and when the only restraints usedwerelimited to soft wrist restraints, the death will be recorded in an internal logthepatient’s name, date of death, name of attending physician or other QLP whois responsible for the care of the patient, medical record number and primarydiagnosis.The patient’s medical record will reflect the date and time the entry was madeintothe internallog.
7.Non-Violent/MedicalRestraints
a.Ordering Non-ViolentRestraint
b.Patients may be restrained for nonviolent reasons only if the patient isinterferingwith essential medical care. Restraining a patient must balance the patient’srightto refuse care and treatment with the patient’s capacity to makedecisions.
i.The use of restraint must be in accordance with the order of a QLP whois responsible for the care of the patient. This includes the authority ofaphysician to delegate this task to the extent recognized under State laworregulatorymechanism and applies to a single restraint episode.
ii.In an emergency situation, an RN may initiate the restraint as long asaphysician is notified as soon as possible generally within 1 hour andatelephone or written order is obtained. (Exception: When the restraintis initiated based on a significant change in the patient’s condition,thephysician must be notified immediately.). Additional trained staffmayassist the RN in the initiation of therestraints.
iii.Orders for the use of restraint must never be written as a standing order oronan as needed basis(PRN).
iv.Each order for restraint must contain at least the followinginformation:
1.The justification or reason the patient requiresrestraint
2.The type of restraint to beapplied
3.The time limit (duration) of therestraint. We should specify in this section what an episode of restraint means in regard to obtaining an order–when it begins and ends.(Hospitals have the flexibility to determine time frames for the restraint of the non-violent, non-self-destructive patient. These time frames should be addressed in policies and procedures.PR.6/SR.3/Page 163).
v.Application ofRestraint
1.Restraint to be applied/removed in accordance with in thefollowing:
a.Generally, restraints should be initiated within 60 minutesofthe order being written subject to availability of thedevices ordered on the unit or other exceptionalcircumstances.
b.The type of restraint used shall be the same as the typeofrestraintordered.
c.Restraints will be applied with safe andappropriatetechniques, evaluated frequently for continuation, andendedat the earliest possibletime.
d.Restraint devices are to be applied/removed in a mannerthatpreserves the dignity, comfort and well–being of thepatient.
e.Soft limb restraints are tied for quickrelease.
f.Restraints are secured out of the patient’sreach.
g.Restraints are not to be tied to moveable bed parts (e.g.,siderails).
h.When possible, the bed should be in the low positionwithside rails up after restraintplacement.
i.Restraint devices are to be applied/removed onlybyauthorized and trained staff. The decision toremoverestraints may be made byRN.
vi.Assessment of the Patient in Restraint for nonviolentreasons.
1.Patients in nonviolent restraint should be assessed/monitored atleastevery two hours (plus or minus 30 minutes) or more frequentlyifnecessary.
2.Appropriately qualified staff will monitor/evaluate the patient onthefollowing, as needed. Each item is not required to be evaluatedwitheach assessment and depends on the patient’s conditionandcircumstances surrounding the patient’s care. (Example: ifthepatient is NPO, the patient would not be asked if he wants adrink).
a.The physical and emotional well-being of thepatient
b.Vital signs (according to PATIENT CARE -Assessmentand Reassessmentpolicy/procedure)
c.Circulation, hydration, hygiene, elimination, range ofmotion,or comfort needs the patient mayhave
d.Skinintegrity
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e.Level of distress andagitation
f.Mentalstatus
g.Cognitive functioning
h.That the patient’s right, dignity, and safety aremaintained
i.Whether the restraint has been appropriatelyapplied
vii.Documentation
1.Restraints should contain the following documentation in thepatient’s medical record asappropriate:
a.The complete dated, timed and authenticated orderforrestraint
b.Alternatives or other less restrictive interventions attemptedorconsidered (asapplicable)
c.The patient condition or symptom(s) that warranted the useofrestraint, and ongoingassessments
d.The patients response to the intervention(s) used,andsignificant changes in patientscondition
e.A description of the patient’s behavior, conditionorsymptoms that warranted use ofrestraint,
f.The intervention used (restrainttype),
g.Alternative interventions attempted (asapplicable)
h.The patient’s response to the intervention, includingrationalfor continueduse
i.Modifications to the plan of care or treatmentplan
j.The plan of care is reviewed and updated when the patientis placed in or removed from restraint, or as needed. Ideally,thetimeframe for modifications to the plan of care shouldbewithin two hours of initiation of restraints and removalofrestraints..
k.Name and title of nurse initiating restraints isrecorded.
2.Definition of Prolonged Restraint: Prolonged restraint is defined asarestraint used for a non-violent reason that exceeds 3 days (72hours).Each Prolonged Restraint Episode is reviewed on anindividualbasis.
3.Termination ofrestraint
a.Restraint will be terminated at the earliest possibletimeregardless of the time length of the order. If restraintis discontinued prior to the expiration of the original order,anew order must be obtained prior to reinitiating the useofrestraint.
Printed documents are considereduncontrolled.
Printed copies are for reference only. Please refer to the electronic copy for the latestversion.
Site: / Title: PATIENT CARE -RestraintsApproved Date:06/05/2015 / EffectiveDate:06/05/2015 / Next ReviewDate:
06/05/2018
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Approved: DocumentControlCommittee, / Supersedes: v.5 PATIENT CARE -Restraints
8.Violent/BehavioralRestraint
a.If a patient is released from restraint and laterexhibits behavior that can only be handled through the use ofrestraint,a new order is required. Trial release is notpermitted.However a temporary release that occurs for the purposeofcaring for a patient’s needs, for example, toileting,feeding,and range of motion, is not considered a trial releaseortermination of restraint as long as the staff remains withthepatientcontinuously.
a.Ordering of Violent/BehavioralRestraint
b.When a patient’s violent or self-destructive behavior presents an immediateorserious danger to the patient or others, immediate action is needed. Thepatientmay berestrained.
c.The use of restraint must be in accordance with the order of a physician ordesigneewho is responsible for the care of thepatient.
1.In an emergency situation, an RN may initiate the restraintaslong as a physician is notified as soon as possiblegenerallywithin 1 hour and a telephone or written order isobtained.(Exception: When the restraint is initiated based onasignificant change in the patient’s condition, thephysicianmust be notified immediately.). Additional trained staffmayassist the RN in the initiation of therestraints.
2.A physician, physician assistant or QLP who has beentrainedaccording to requirements must see the patient within onehourafter initiation of the intervention to evaluate thepatient’s immediate situation, reaction to the intervention, medicalandcondition, and the need to continue or terminate therestraint.
3.Orders for the use of restraint must never be written as astandingorder or on an as needed basis(PRN).
4.Each order for restraint must contain at least thefollowinginformation:
5.The name of the physician ordering therestraint
6.The time limit (duration) of therestraint
a.Up to four (4) hours for adults age 18 andolder.
b.Up to two (2) hours for children and adolescents ages 9to17
c.Up to one (1) hour for patients under age9.
7.If a restraint applied for violent reasons continues beyond24hours, an assessment by the physician or QLP must occurand reviewed as a prolonged restraint
b.Application of Restraint for Violent/BehavioralReasons
1.Restraints shall be applied/removed by appropriatelyqualifiedand trained staff. The decision to remove restraints maybemade byRN.
2.The type of restraint used shall be the same as the type ofrestraintordered.
3.Restraints will be applied with safe and appropriatetechniques,evaluated frequently for continuation and ended at theearliestpossible time.
4.Restraints devices are to be applied /removed in accordancewithmanufacturer’s instructions and used in manner consistentwiththeir intendedpurpose.
5.Restraint devices are to be applied/removed in a mannerthatpreserves the dignity, comfort, and well-being of thepatient.
6.Restraints will be secured to the bed frame if being usedwhilethe patient is in bed. Restraint should never be tied to thesiderails. Restraints should be secured so that they may bereleasedquickly in the event of anemergency.
c.Simultaneous use of Seclusion andRestraint
a. Restraint and seclusion may not to beusedsimultaneously.
d.Monitoring/Evaluation of a patient in Violent/BehavioralRestraint
1.Appropriately qualified staff will monitor /evaluate the patientas needed. Each item is not required to be evaluated witheachassessment and depends on the patient’s conditionandcircumstances surrounding the patient’s care. (Example: ifthepatient is NPO, the patient would not be asked if he wantsadrink).
i.Adequate Breathing
ii.Circulation
iii.Any hydration, hygiene, elimination, range of motion, orcomfortneeds the patient mayhave
iv.Skinintegrity
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Approved: DocumentControlCommittee, / Supersedes: v.5 PATIENT CARE -Restraints
v.Level of distress andagitation
vi.Mentalstatus
vii.Cognitive functioning
viii.That the patient’s rights, dignity, and safety aremaintained
ix.Whether less restrictive measures arepossible
x.Changes in the patient’s clinical condition required to initiatetheremoval ofrestraint
xi.Whether the restraint has been appropriatelyapplied.
xii.Patients placed in violent restraints will be evaluated /monitoredat least every 15 minutes or more frequently ifnecessary
a.Documentation
For each episode of restraint, the following are documented inthemedical record asappropriate.
i.A description of the patient’s behavior, condition orsymptoms that warranted use ofrestraint,
ii.Interventionsused,
iii.Alternative interventions attempted (asapplicable),
iv.Each in-person evaluation and re-evaluation of thepatient
v.The patient’s response to the intervention, includingrationalefor continueduse