CMS SOM App. A, Tag A-0171

(i) Each order for restraint or seclusion used for the management of violent or self-destructive

behavior that jeopardizes the immediate physical safety of the patient, a staff member, or

others may only be renewed in accordance with the following limits for up to a total of 24

hours:

(A) 4 hours for adults 18 years of age or older;

(B) 2 hours for children and adolescents 9 to 17 years of age; or

(C) 1 hour for children under 9 years of age; and

Interpretive Guidelines §482.13(e)(8)(i)

Patients of all ages are vulnerable and at risk when restrained or secluded to manage violent or self-destructive behavior. Therefore, time limits have been established for each order for restraint or

seclusion used to manage violent or self-destructive behavior. State law may require more restrictive

time limits. These time limits do not apply to orders for restraint used to manage non-violent or non-self-destructive behavior. However, the requirement that restraint use be ended at the earliest possible

time applies to all uses of restraint.

In the final rule on the use of restraint or seclusion, CMS did not include specific criteria for

differentiating between emergency situations where the patient’s behavior is violent or self-destructive

and jeopardizes the immediate physical safety of the patient, a staff member, or others, and non-emergency use of restraint. Clinicians are adept at identifying various behaviors and symptoms, and can

readily recognize violent and self-destructive behavior that jeopardizes the immediate physical safety of

the patient, a staff member, or others. Asking clinicians to act based on an evaluation of the patient’s

behavior is no different than relying on the clinical judgment that they use daily in assessing the needs of

each patient and taking actions to meet those individual needs.

The regulation identifies maximum time limits on the length of each order for restraint or seclusion

based on age. The physician or other LIP has the discretion to write the order for a shorter length of

time. The length-of-order requirement identifies critical points at which there is mandatory contact with

a physician or other LIP responsible for the care of the patient. In addition, the time limits do not dictate

how long a patient should remain in restraint or seclusion. Staff is expected to continually assess and

monitor the patient to ensure that the patient is released from restraint or seclusion at the earliest

possible time. Restraint or seclusion may only be employed while the unsafe situation continues. Once

the unsafe situation ends, the use of restraint or seclusion should be discontinued. The regulation

explicitly states that the intervention must be discontinued at the earliest possible time, regardless of the

length of time identified in the order. For example, if a patient’s behavior is no longer violent or self-destructive 20 minutes after the intervention is initiated, then the restraint or seclusion should be

discontinued, even if the order was given for up to 4 hours. If restraint or seclusion is discontinued prior

to the expiration of the original order, a new order must be obtained prior to reinitiating the use of

restraint or seclusion.

At the end of the time frame, if the continued use of restraint or seclusion to manage violent or self-destructive behavior is deemed necessary based on an individualized patient assessment, another order is

required. When the original order is about to expire, an RN must contact the physician or other LIP,

report the results of his or her most recent assessment and request that the original order be renewed (not

to exceed the time limits established in the regulation). Whether or not an onsite assessment is

necessary prior to renewing the order is left to the discretion of the physician or other LIP in conjunction

with a discussion with the RN who is over-seeing the care of the patient. Another 1-hour face-to-face

patient evaluation (see

§482.13(e)(12) and the related interpretive guidance) is not required when the

original order is renewed.

The original restraint or seclusion order may only be renewed within the required time limits for up to a

total of 24 hours. After the original order expires, a physician or other LIP must see and assess the

patient before issuing a new order.

EXCEPTION: Repetitive self-mutilating behaviors – see interpretive guidance for §482.13(e)(6).

Survey Procedures §482.13(e)(8)(i)

• When restraint or seclusion is used to manage violent or self-destructive behavior, do orders contain

the appropriate time frames based on the patient’s age? Does the total number of hours covered by

an order or its renewal exceed 24 hours?

• If more restrictive State laws apply, are they being followed?

• Is the renewal order for restraint or seclusion based on a comprehensive individual patient

assessment?

• Is there evidence in the patient’s medical record that the symptoms necessitating the continued use

of restraint or seclusion have persisted?