Policy Resources: Restraints and Seclusion - Rules Chart
Restraint and Seclusion
CMS Revised Rules (Key Provisions)
| Provisions | Interim Final Rule For Hospitalsi | Final Rule For Hospitalsii |
|---|---|---|
| Effective Date | August 1999 | January 8, 2007 |
| Definition of Restraint | Any manual method or 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. | 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. 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 bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort). |
| Chemical Restraints or Inappropriate Use of Medication | A medication used to control behavior or to restrict the patient's freedom of movement and is not a standard treatment for the patient's medical or psychological condition. | A medication used to control behavior or to restrict the patient's freedom of movement and is not a standard treatment for the patient's medical or psychological condition. |
| Definition of Seclusion | The involuntary confinement of a person in a room or an area where the person is physically prevented from leaving. | The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. |
| Definition of Time-Out | None | None |
| Standard for Use | 1) emergency situations if needed to ensure the patient's physical safety 2) less restrictive interventions have been determined to be ineffective 3) in least restrictive manner and with safe techniques 4) end at earliest possible time |
1) Restraint may be used to ensure the patient's immediate physical safety, even if the patient is not violent or self-destructive. 2) Seclusion may only be used for the management of violent or self-destructive behavior that is an immediate threat to the patient's physical safety. 3) 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. 4) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm. 5) The use of restraint or seclusion must be implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. 6) Must be discontinued at the earliest possible time. |
| Orders | Physician or Independent Licensed Practitioner. Treating physician must be consulted as soon as possible (if did not order use). | 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 as specified under § 482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law. The attending physician must be consulted as soon as possible if the attending physician did not order the restraint or seclusion. |
| PRN Orders | No | No |
| Time Limits | Time in written orders but not longer than: 4 hours for adults; 2 hours for ages 9-17; and 1 hour for under age 9. Total limit of 24 hours. |
Time in written orders but not longer than: 4 hours for adults; 2 hours for ages 9-17; and 1 hour for under age 9. Total limit of 24 hours. |
| In-Person Evaluation of Patient | 1) Physician or Independent Licensed Practitioner must see and evaluate the need for use within 1 hour after initiation 2) If patient is no longer in restraints at end of verbal order the physician or independent licensed practitioner must still see and evaluate the patient within one hour. |
Face-to-face within 1 hour by 1) Physician or Licensed Independent Practitioner or 2) Registered Nurse or Physician Assistant who has been trained according to new requirements. |
| Simultaneous Use of Restraint and Seclusion | No, unless patient is continually monitored face-to-face by an assigned, trained staff member or continually monitored in close proximity by trained staff using both video and audio equipment. | No, unless patient is continually monitored face-to-face by an assigned, trained staff member or continually monitored in close proximity by trained staff using both video and audio equipment. |
| Renewal of Original Order | Yes. Up to maximum time of 24 hours using same time limits. | Yes. Up to maximum time of 24 hours using same time limits. |
| New Orders | Not specified. Restraint and seclusion use must be in accordance with a written modification to patient's plan of care. |
Restraint and seclusion use must be in accordance with a written modification to patient's plan of care. Documentation in patient's medical record must include the following: 1) 1-hour face-to-face medical and behavioral evaluation if 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 patient's condition or symptom(s) that warranted the use of the restraint or seclusion; and 5) the patient's response to the intervention(s) used, including the rationale for the continued use of the intervention. |
| Monitoring and Assessment | Continual monitoring, assessment and reevaluation. | Monitoring, assessment and reevaluation at an interval determined by hospital policy. |
| Reporting | To HCFAiii of any death that occurs with use (during use or if reasonably assumed result of use) | To CMS of any death that occurs 1) during restraint or seclusion; 2) within 24 hours after removal from restraint or seclusion; and 3) within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or seclusion contributed directly or indirectly to a patient's death. "Reasonable to assume" includes (but is not limited to) deaths related to restrictions of movement, death related to chest compression, restriction of breathing or asphyxiation. Must report by phone to CMS by close of next business day and document date and time of the call in the patient's medical record. |
| Training and Education | All staff with direct patient contact (safe use of, alternative methods, etc.). | Intervals: Staff must be trained and able to demonstrate competency 1) before performing restraint or seclusion, 2) as part of orientation, and 3) subsequently, on a periodic basis. Content: Staff must have education, training, and demonstrated knowledge based on specific needs of patient population. Minimum of 1) techniques to identify staff and patient behaviors, events, and environmental factors that may trigger need to use restraint or seclusion, 2) use of nonphysical intervention skills, 3) choosing least restrictive intervention based on individualized assessment, 4) safe application of restraint and seclusion, including recognition of and response to signs of physical and psychological distress, 5) clinical identifications that restraint or seclusion is no longer necessary, 6) monitoring physical and psychological well-being of patient (e.g., respiratory and circulatory status, skin integrity, vital signs), and 7) first aid and current CPR certification. Trainer requirements: Must be qualified by education, training, and experience to address patient behaviors. Training documentation: Must document in staff personnel records completion of training and competency demonstration. |
| Debriefing | Not specified. | Not specified. |
| Covered Settings | Hospitals receiving Medicaid and Medicare Funds; Rules for RTC's other than those licensed as hospitals to be released spring 2000. | All hospitals, including short-term psychiatric rehabilitation, long-term, children's and alcohol/drug treatment facilities that receive Medicaid and Medicare funds. |
i Medicare and Medicaid Programs: Hospitals Conditions of Participation (42 CFR Part 482),
published in the Federal Register on July 2, 1999 (Volume 64, Number 129; pages 36069-36089).
ii Medicare and Medicaid Programs; Hospitals Conditions of Participation: Patients' Rights (42 CFR Part 482), published in the Federal Register on December 8, 2006 (Volume 71, Number 236; pages 71378-71428). View the regulations.
iii The Health Care Financing Administration ("HCFA") is now known as the Center for Medicare and Medicaid Services ("CMS").
