Managing Restraint Documentation

Restraint Classification (CMS Categories)

• Non-violent/non-self-destructive behavior (medical-surgical restraints): Used to prevent patient from removing medically necessary devices (ET tube, central line, feeding tube)
  • Order renewal: every calendar day
  • Face-to-face assessment: within 24 hours by physician/LIP
• Violent/self-destructive behavior (behavioral restraints): Used when patient is an imminent danger to self or others
  • Order renewal: every 4 hours for adults ≥ 18; every 2 hours for ages 9–17; every 1 hour for age < 9
  • Face-to-face assessment: within 1 hour by physician/LIP

Step 1 — Obtain and Document the Restraint Order

1. Obtain an order from a physician or other licensed independent practitioner (LIP)
2. Verify the order includes all required elements:
   • Clinical justification (specific behaviors or risks)
   • Type of restraint (wrist, ankle, vest, mitt, 4-point, chemical)
   • Duration (per CMS category — never PRN or standing orders)
   • Monitoring parameters
3. Emergency exception: A registered nurse may initiate restraints in an emergency and must obtain a physician/LIP order within 1 hour (CMS requirement)
4. Document the order with date, time, ordering provider, restraint type, and clinical justification
5. Never accept a PRN restraint order — each restraint episode requires a new order

Step 2 — Apply Restraints Safely

1. Select the least restrictive device that will effectively address the safety concern
2. Apply per manufacturer instructions:
   • Two-finger space between restraint and skin
   • Quick-release knots tied to the bed frame (not the side rail)
   • Ensure patient can reach call light
   • Position patient to maintain airway and respiratory function
3. Verify circulation distal to restraints: pulses, capillary refill, sensation, skin color, temperature
4. Confirm the patient cannot reach lines, tubes, or equipment that the restraint is intended to protect
5. Document the application: time, type, location, method of securement, patient's immediate response

Step 3 — Monitor the Restrained Patient

CMS requires continuous monitoring. Document the following at minimum intervals:

Every 1–2 Hours (Per Institutional Policy; CMS Minimum)

1. Circulation check: pulses, sensation, skin color, temperature, and capillary refill distal to each restraint
2. Skin integrity: inspect skin under and around each restraint device
3. Range of motion: release one limb at a time for ROM exercises; document completion
4. Repositioning: reposition patient for comfort and pressure injury prevention
5. Nutrition and hydration: offer fluids and snacks; document intake
6. Toileting: offer toileting assistance or assess continence product
7. Pain assessment: assess for pain related to restraints or underlying condition
8. Behavioral assessment: ongoing evaluation of continued need for restraint

Document Each Monitoring Interval

• Time of assessment
• Circulatory status findings
• Skin condition
• ROM exercises performed
• Repositioning completed
• Nutrition/hydration offered (accepted or refused)
• Toileting offered (accepted or refused)
• Patient's behavior and mental status
• Continued clinical justification for restraint (or removal if no longer indicated)

Step 4 — Conduct Required Face-to-Face Assessments

For Non-Violent/Non-Self-Destructive Restraints

• Physician/LIP face-to-face assessment within 24 hours of restraint initiation
• Assessment must evaluate: patient's physical and psychological status, need for continued restraint, appropriateness of the care plan

For Violent/Self-Destructive Behavior Restraints

• Physician/LIP face-to-face assessment within 1 hour of restraint initiation
• Assessment must include: patient's physical and psychological status, immediate situation, patient's reaction to restraint, medical and behavioral condition
• Order must be renewed per age-specific intervals (4h/2h/1h) with new assessment each time

Document the Face-to-Face Assessment

• Provider name and credentials
• Date and time of assessment
• Findings: physical status, psychological status, behavioral status
• Clinical determination: continue restraint, modify restraint, or discontinue

Step 5 — Reassess for Discontinuation

Restraints must be removed at the earliest clinically appropriate time:

1. Evaluate at each monitoring interval whether the clinical indication for restraint still exists
2. Trial release: Attempt removal when patient appears calm, oriented, and cooperative
3. Assess behavioral response during trial release
4. Discontinue restraint when:
   • Patient is no longer at imminent risk of harm to self or others
   • Underlying cause has been addressed (delirium resolved, medication adjusted, pain controlled)
   • Less restrictive alternatives are now effective
   • Patient's condition has stabilized
5. Document discontinuation: time, clinical rationale, patient's condition at time of removal, plan for continued monitoring

Step 6 — Conduct and Document Restraint-Related Education

1. Patient education: Explain the reason for restraints, expected duration, rights including the right to be free from restraints when no longer clinically necessary
2. Family education: Explain the clinical justification, monitoring plan, and how the family can support the patient
3. Document education provided, learner response, and questions/concerns addressed
4. Address family concerns empathetically — restraint use is distressing for families; document any disagreement and plan for resolution

Checkpoint B — Restraint Documentation Review

Per-Episode Verification

• Restraint order obtained within required timeframe (immediate for planned; within 1 hour for emergency)
• Order includes all required elements (no PRN or standing orders)
• Less restrictive alternatives documented as attempted and failed
• Application documented: type, location, securement method, time
• Monitoring documented at required intervals (minimum every 1–2 hours per institutional policy)
• Face-to-face assessment completed within required timeframe (1 hour for behavioral; 24 hours for medical)
• Order renewed within CMS timeframes
• Ongoing assessment for discontinuation documented
• Patient/family education documented

Compliance Check

• No PRN restraint orders in the medical record
• No restraint continuation beyond order expiration without renewal
• No gap in monitoring documentation
• Circulatory checks, ROM, repositioning, nutrition, hydration, toileting all documented at each interval
• Clinical justification documented for each shift that restraints continue

Quality Audit

• Restraint order obtained per CMS timeframe requirements (planned or within 1 hour for emergency)
• All required order elements present: type, justification, duration, monitoring parameters
• Less restrictive alternatives documented for every restraint episode
• Face-to-face assessment by physician/LIP completed within 1 hour (behavioral) or 24 hours (medical)
• Monitoring documented at every required interval with all mandated elements
• Order renewal completed before expiration per CMS category timeframes
• Restraint prevalence tracked per NDNQI reporting (restraint days per 1,000 patient days)
• Zero restraint-related injuries or deaths (sentinel event if death occurs during restraint use)
• Compliant with CMS CoP §482.13 (Patient Rights — restraint and seclusion requirements)
• Compliant with Joint Commission PC.03.05.01 through PC.03.05.19 (restraint and seclusion standards)
• State-specific restraint regulations met (some states have stricter requirements than CMS)

Guidelines

• CMS CoP §482.13: Patients have the right to be free from restraints used for coercion, discipline, convenience, or retaliation; restraints may only be used when clinically necessary to protect the patient or others from imminent harm
• CMS Interpretive Guidelines: Appendix A — provides detailed requirements for restraint orders, monitoring, face-to-face assessments, order renewals, training, and death reporting
• Joint Commission: PC.03.05 standards — restraint use must be individualized, clinically justified, time-limited, and continuously monitored; organizations must track and reduce restraint use
• CMS Death Reporting: Any death occurring during restraint use or within 24 hours of restraint removal must be reported to CMS within 1 business day; death within 1 week where restraints contributed must be reported
• NDNQI: Restraint prevalence (physical restraint days per 1,000 patient days) is a nursing-sensitive quality indicator; national benchmark trending shows decline
• Chemical restraints: Medications used to restrict patient movement or behavior (not part of standard treatment) are subject to the same requirements as physical restraints
• Seclusion: Involuntary confinement in a locked room; subject to the same CMS requirements as behavioral restraints; CMS prohibits simultaneous seclusion and restraint except when face-to-face assessment determines both are necessary
• Scope of practice: RN initiates emergency restraints and coordinates ongoing monitoring; physician/LIP writes orders and performs face-to-face assessments; all nursing staff performing restraint application must be trained in safe application, monitoring, and de-escalation
• Training requirement: CMS requires that all staff involved in restraint application demonstrate competency in safe application, monitoring, de-escalation, and recognizing complications