Physical restraints in healthcare settings, such as hospitals and nursing homes, are highly regulated and intended only for patient safety. A physical restraint is any device or method that restricts a patient’s freedom of movement or access to their body that they cannot easily remove. Because restraints limit patient rights and carry risks like injury or psychological distress, strict time limits and monitoring protocols are mandated by regulatory bodies like the Centers for Medicare & Medicaid Services (CMS). These regulations dictate how often a patient must be checked and how frequently the restraints must be released to provide care.
Criteria for Determining the Necessity of Restraints
Restraints are a measure of last resort, used only when less restrictive interventions have failed to protect the patient or others from imminent harm. Their use must be justified by the patient’s immediate need for safety, such as preventing the removal of a life-sustaining tube or managing violent behavior. Restraints are strictly prohibited as a form of discipline, staff convenience, or retaliation.
Before application, staff must attempt alternative strategies, including increased supervision, reorientation, or relocation. The rationale for choosing a restraint must be clearly documented, based on an individualized assessment of the patient’s status. The goal is always to discontinue the restraint at the earliest possible time once the immediate danger has passed.
Mandatory Monitoring and Reassessment Intervals
Continuous observation is distinct from the physical release of the restraint, focusing on the patient’s immediate well-being and the device’s effect. For patients in physical restraints, especially those used for behavioral management, staff must conduct and document an assessment at least every 15 minutes. This frequent monitoring checks for potential injury and ensures the patient’s physical and psychological needs are met.
During these regular checks, staff must assess circulation in the restrained limbs, check skin integrity to prevent pressure injuries, and monitor vital signs. The patient’s level of distress, agitation, and mental status must also be assessed to determine if the restraint remains necessary. For patients in four-point or five-point restraints for medical reasons, the assessment frequency is typically every 15 minutes, while other medical restraints may require checks at least every hour.
The Requirement for Physical Release and Repositioning
The core requirement for patient care is the mandatory physical release and repositioning of the patient, which must occur at least every two hours. This action involves the temporary, complete removal of the restraint device. The purpose of this scheduled release is to prevent complications associated with prolonged immobilization.
During the minimum two-hour release period, staff must provide range-of-motion exercises to the restrained limbs to prevent joint stiffness and maintain muscle function. Essential needs must be addressed, including offering fluids and nutrition, assisting with toileting and hygiene, and repositioning the patient to alleviate pressure points. This time also serves as a formal opportunity for the care team to reassess whether the restraint is still needed.
Duration of Orders and Required Renewal Timelines
A restraint order is time-limited and must expire, requiring a new assessment and order to continue use. The maximum duration of a single order depends on the reason for the restraint and the patient’s age. Orders for restraints used to manage violent or self-destructive behavior have very short maximum lengths to ensure rapid reevaluation.
An initial order for a behavioral restraint for an adult is limited to four hours. For adolescents aged 9 to 17, the maximum is two hours, and for children under nine, it is one hour. In contrast, a restraint order for non-violent medical reasons, such as preventing a patient from dislodging a medical device, can typically be written for a maximum of 12 or 24 hours. Regardless of the initial order length, a physician or licensed independent practitioner must conduct a face-to-face assessment before renewing the order after the first 24 hours of continuous restraint use.