CMS SOM App. A, Tag A-0161

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).

Interpretive Guidelines §482.13(e)(1)(i)(C)

The devices and methods listed here would not be considered restraints, and, therefore, not subject to

these requirements. These devices and methods are typically used in medical-surgical care.

Use of an IV arm board to stabilize an IV line is generally not considered a restraint. However, if the

arm board is tied down (or otherwise attached to the bed), or the entire limb is immobilized such that the

patient cannot access his or her body, the use of the arm board would be considered a restraint.

A mechanical support used to achieve proper body position, balance, or alignment so as to allow

greater freedom of mobility than would be possible without the use of such a mechanical support is not

considered a restraint. For example, some patients lack the ability to walk without the use of leg braces,

or to sit upright without neck, head, or back braces.

A medically necessary positioning or securing device used to maintain the position, limit mobility, or

temporarily immobilize the patient during medical, dental, diagnostic, or surgical procedures is not

considered a restraint.

Recovery from anesthesia that occurs when the patient is in a critical care or postanesthesia care unit is

considered part of the surgical procedure; therefore, medically necessary restraint use in this setting

would not need to meet the requirements of the regulation. However, if the intervention is maintained

when the patient is transferred to another unit, or recovers from the effects of the anesthesia (whichever

occurs first), a restraint order would be necessary and the requirements of standard (e) would apply.

Many types of hand mitts would not be considered restraint. However, pinning or otherwise attaching

those same mitts to bedding or using a wrist restraint in conjunction with the hand mitts would meet the

definition of restraint and the requirements would apply. In addition, if the mitts are applied so tightly

that the patient's hand or fingers are immobilized, this would be considered restraint and the

requirements would apply. Likewise, if the mitts are so bulky that the patient's ability to use their hands

is significantly reduced, this would be considered restraint and the requirements would apply.

NOTE: Because this definition of physical restraint does not name each device and situation that can

be used to immobilize or reduce the ability of the patient to move his or her arms, legs, body

or head freely, it promotes looking at each patient situation on a case-by-case basis.

In addition, if a patient can easily remove a device, the device would not be considered a restraint. In

this context, “easily remove” means that the manual method, device, material, or equipment can be

removed intentionally by the patient in the same manner as it was applied by the staff (e.g., side rails are

put down, not climbed over; buckles are intentionally unbuckled; ties or knots are intentionally untied;

etc.) considering the patient’s physical condition and ability to accomplish the objective (e.g., transfer to

a chair, get to the bathroom in time).

Age or developmentally appropriate protective safety interventions (such as stroller safety belts,

swing safety belts, high chair lap belts, raised crib rails, and crib covers) that a safety-conscious child

care provider outside a health care setting would utilize to protect an infant, toddler, or preschool-aged

child would not be considered restraint or seclusion for the purposes of this regulation. The use of these

safety interventions needs to be addressed in the hospital’s policies or procedures.

Physical Escort

A physical escort would include a “light” grasp to escort the patient to a desired location. If the patient

can easily remove or escape the grasp, this would not be considered physical restraint. However, if the

patient cannot easily remove or escape the grasp, this would be considered physical restraint and all the

requirements would apply.

Physical holding

The regulation permits the physical holding of a patient for the purpose of conducting routine physical

examinations or tests. However, patients do have the right to refuse treatment. See §482.13(b)(2). This

includes the right to refuse physical examinations or tests. Holding a patient in a manner that restricts

the patient's movement against the patient’s will is considered restraint. This includes holds that some

member of the medical community may term “therapeutic holds.” Many deaths have occurred while

employing these practices. Physically holding a patient can be just as restrictive, and just as dangerous,

as restraining methods that involve devices. Physically holding a patient during a forced psychotropic

medication procedure is considered a restraint and is not included in this exception.

For the purposes of this regulation, a staff member picking up, redirecting, or holding an infant, toddler,

or preschool-aged child to comfort the patient is not considered restraint.

Physical Holding for Forced Medications

The application of force to physically hold a patient, in order to administer a medication against the

patient’s wishes, is considered restraint. The patient has a right to be free of restraint and, in accordance

with §482.13(b)(2), 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 patients 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 is necessary with a violent patient, the 1-hour face-to-face evaluation requirement would also

apply.

In certain circumstances, a patient may consent to an injection or procedure, but may not be able to hold

still for an injection, or cooperate with a procedure. In such circumstances, and at the patient’s request,

staff may “hold” the patient in order to safely administer an injection (or obtain a blood sample, or insert

an intravenous line, if applicable) or to conduct a procedure. This is not considered restraint.

Side rails

A restraint does not include methods that protect the patient from falling out of bed. Examples include

raising the side rails when a patient is: on a stretcher, recovering from anesthesia, sedated, experiencing

involuntary movement, or on certain types of therapeutic beds to prevent the patient from falling out of

the bed. The use of side rails in these situations protects the patient from falling out of bed and,

therefore, would not be subject to the requirements of standard (e).

However, side rails are frequently not used as a method to prevent the patient from falling out of bed,

but instead, used to restrict the patient’s freedom to exit the bed. The use of side rails to prevent the

patient from exiting the bed would be considered a restraint and would be subject to the requirements of

standard (e). The use of side rails is inherently risky, particularly if the patient is elderly or disoriented.

Frail elderly patients may be at risk for entrapment between the mattress or bed frame and the side rail.

Disoriented patients may view a raised side rail as a barrier to climb over, may slide between raised,

segmented side rails, or may scoot to the end of the bed to get around a raised side rail and exit the bed.

When attempting to leave the bed by any of these routes, the patient is at risk for entrapment,

entanglement, or falling from a greater height posed by the raised side rail, with a possibility for

sustaining greater injury or death than if the patient had fallen from the height of a lowered bed without

raised side rails. In short, the patient may have an increased risk for a fall or other injury by attempting

to exit the bed with the side rails raised. The risk presented by side rail use should be weighed against

the risk presented by the patient's behavior as ascertained through individualized assessment.

When the clinician raises all four side rails in order to restrain a patient, defined in this regulation as

immobilizing or reducing the ability of a patient to move his or her arms, legs, body, or head freely to

ensure the immediate physical safety of the patient, then the requirements of this rule apply. Raising

fewer than four side rails when the bed has segmented side rails would not necessarily immobilize or

reduce the ability of a patient to move freely as defined in the regulation. For example, if the side rails

are segmented and all but one segment are raised to allow the patient to freely exit the bed, the side rail

is not acting as a restraint and the requirements of this rule would not apply. Conversely, if a patient is

not physically able to get out of bed regardless of whether the side rails are raised or not, raising all four

side rails for this patient would not be considered restraint because the side rails have no impact on the

patient’s freedom of movement. In this example, the use of all four side rails would not be considered

restraint. Therefore, the requirements of this rule would not apply.

When a patient is on a bed that constantly moves to improve circulation or prevents skin breakdown,

raised side rails are a safety intervention to prevent the patient from falling out of bed and are not

viewed as restraint.

When a patient is placed on seizure precautions and all side rails are raised, the use of side rails would

not be considered restraint. The use of padded side rails in this situation should protect the patient from

harm; including falling out of bed should the patient have a seizure.

Placement in a crib with raised rails is an age-appropriate standard safety practice for every infant or

toddler. Therefore, placement of an infant or toddler in the crib with raised rails would not be

considered restraint.

If the patient is on a stretcher (a narrow, elevated, and highly mobile cart used to transport patients and

to evaluate or treat patients), there is an increased risk of falling from a stretcher without raised side rails

due to its narrow width, and mobility. In addition, because stretchers are elevated platforms, the risk of

patient injury due to a fall is significant. Therefore, the use of raised side rails on stretchers is not

considered restraint but a prudent safety intervention. Likewise, the use of a seat belt when transporting

a patient in a wheelchair is not considered restraint.

Survey Procedures §482.13(e)(1)(i)(C)

• Determine whether the hospital’s policies and procedures employ a definition or description of

what constitutes a restraint that is consistent with the regulation.

• While touring hospital units look for bed side rail use to determine whether it is consistent with

the definition of a restraint. Where bed side rails are being used as a restraint, check the medical

record for appropriate documentation.

• Interview hospital staff to determine whether they know the definition of a restraint, particularly

with respect to use of bed side rails.