Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
RESTRAINTS AND SECLUSION 
State Policies 
for 
Psychiatric Hospitals 
JUNE GIBBS BROWN 
Inspector General 
AUGUST 2000 
OEI-04-99-00150  OFFICE OF INSPECTOR GENERAL 
Public Law 95-452, as amended by Public Law 100-504, mandated the mission of the Office of 
Inspector General.  That mission is to protect the integrity of the Department of Health and 
Human Services programs as well as the health and welfare of beneficiaries served by them.  This 
statutory mission is carried out through a nationwide program of audits, investigations, 
inspections, sanctions, and fraud alerts.  The Inspector General informs the Secretary of program 
and management problems, and recommends legislative, regulatory, and operational approaches 
to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections is one of several components of the Office of Inspector 
General.  It conducts short-term management and program evaluations (called inspections) that 
focus on issues of concern to the Department, the Congress, and the public.  Inspection reports 
provide findings and recommendations on the efficiency, vulnerability, and effectiveness of 
departmental programs. 
OEI's Atlanta Regional Office prepared this report under the direction of Jesse J. Flowers, 
Regional Inspector General, and Christopher H. Koehler, Deputy Regional Inspector General. 
Principal OEI staff included: 
Dwayne Grant, Team Leader  Seth Rosenblatt, Program Analyst 
Greg Jones, Program Analyst  Elise Stein, Program Specialist 
Lisa Keating, Program Analyst  Glen Thomas, Program Analyst 
Alan Levine, Program Specialist  Joe Townsel, Program Analyst 
Graham Rawsthorn, Program Analyst 
To obtain copies of this report, please call the Atlanta Regional Office at 404-562-7723.  Reports 
are also available on the World Wide Web at our home page address: 
http://www.dhhs.gov/progorg/oei  Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
RESTRAINTS AND SECLUSION 
State Policies 
for 
Psychiatric Hospitals 
JUNE GIBBS BROWN 
Inspector General 
AUGUST 2000 
OEI-04-99-00150  TABLE  OF  CONTENTS 
EXECUTIVE SUMMARY  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4

FINDINGS

Initiating Restraints or Seclusion  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Obtaining Physician Orders  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Limiting Duration of Physician Orders  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Monitoring Patients  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

RECOMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  14

AGENCY COMMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  15

APPENDIX

Agency Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

HCFA  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

SAMHSA  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
 EXECUTIVE  SUMMARY 
PURPOSE 
To describe State policies for restraints and seclusion in psychiatric hospitals. 
BACKGROUND 
Over five million people experience severe mental illnesses each year.  In 1998, Medicare 
and Medicaid paid almost $6 billion to provide mental health care to over 500,000 
beneficiaries in psychiatric hospitals.  Mental health care may be provided in publicly 
(State) or privately owned hospitals.  During hospitalization, persons with mental illness 
may be placed in restraints or seclusion. 
The use of restraints and seclusion may be appropriate in some circumstances, but in 
others it may be inappropriate and abusive.  In recent years, various reports have linked 
numerous deaths to inappropriate use of restraints and seclusion.  Mental health advocates 
have expressed concern that hospitals are too quick to restrain or seclude patients, do not 
properly monitor them, and keep them restrained or secluded too long. 
Such reports raised concern in the Congress, Department of Health and Human Services, 
and States on policies, standards and oversight for using restraints and seclusion.  In 
response, the Health Care Financing Administration issued new Patients Rights Condition 
of Participation regulations for hospitals, effective in August 1999.  The new standards 
allow using restraints and seclusion in emergency situations, but only when less restrictive 
interventions are determined ineffective for ensuring the safety of patients and others. 
FINDINGS 
Many State policies already met some of the new Patients Rights Condition of 
Participation standards.  However, other State policies for both public and private 
psychiatric hospitals did not.  State policies for use of restraints and seclusion in private 
psychiatric hospitals more frequently fell short of the new standards. 
Initiating Restraints and Seclusion 
The Health Care Financing Administrations new Patients Rights Condition of 
Participation requires all staff with direct patient contact to have ongoing education and 
training in the appropriate and safe use of restraints and seclusion, and in alternative 
methods to avoid the use of restraints and seclusion. 
State policies generally specify who can initiate a restraint or seclusion.  In over 74 
percent of the States only a doctor or nurse had authority to initiate a restraint or seclusion 
1 
Restraints and Seclusion: Policies for Psychiatric Hospitals  OEI-04-99-00150  in public psychiatric hospitals.  Likewise, 73 percent of the States have the same 
restriction for private psychiatric hospitals.  However, hospital staff said that in an 
emergency it is often necessary for the closest employee to restrain a patient until other 
trained staff arrive. 
Physician Orders 
The Health Care Financing Administrations new Patients Rights Condition of 
Participation requires that a physician or other licensed independent practitioner see and 
evaluate the need for restraint and seclusion within 1 hour after the initiation of this 
intervention. 
Policies for 78 percent of States require a physician order within 1 hour of initiating a 
restraint or seclusion in public psychiatric hospitals.  Likewise, 60 percent did so for 
private psychiatric hospitals.  However, most State policies did not specify a see and 
evaluate requirement. To illustrate, only 2 States required their public hospitals to meet 
the see and evaluate requirement.  None did so for private hospitals.  The other States 
allowed physician orders for restraint and seclusion to be given over the telephone. 
In their response to the Health Care Financing Administrations new Patients Rights 
Condition of Participation interim final rule, private associations for physicians and 
hospitals voiced opposition to the new 1 hour see and evaluate requirement.  They said 
it will be costly and difficult to implement.  They also believe the requirement 
inappropriately dictates medical practice. 
Time Limits 
The Health Care Financing Administrations new Patients Rights Condition of 
Participation limits duration of physician and licensed independent practitioner orders for 
restraints and seclusion to 4 hours for adults.  However, only 43 percent of States had a 
limit of 4 hours for public psychiatric hospitals.  Only 9 percent of the States set such a 
limit for private psychiatric hospitals. 
Further, only 20 percent of the State policies for physician orders in public psychiatric 
hospitals met the Health Care Financing Administrations new Patients Rights Condition 
of Participation standard of a 2 hour time limit for adolescents, and a 1 hour limit for 
children.  None of the States had similar standards for adolescents and children in private 
psychiatric hospitals. 
Patient Monitoring 
The Health Care Financing Administrations new Patients Rights Condition of 
Participation requires continual (close, recurring) monitoring of patients that are either 
restrained or secluded.  Many States met this standard.  Eighty five percent of State 
policies for public psychiatric hospitals required monitoring every 15 minutes or less. 
Only 48 percent of the States required such monitoring in private psychiatric hospitals. 
2 
Restraints and Seclusion: Policies for Psychiatric Hospitals  OEI-04-99-00150  A few States had higher standards for patient monitoring.  Four States required 
continuous (constant) monitoring in public psychiatric hospitals, while one State did so for 
private psychiatric hospitals. 
RECOMMENDATION 
We recommend that HCFA work aggressively with States and accreditation 
organizations to quickly raise psychiatric hospital compliance with the new Patients 
Rights Condition of Participation where necessary.  Particular attention should be 
given to policies for private psychiatric hospitals. 
AGENCY COMMENTS 
Both the Health Care Financing Administration and the Substance Abuse and Mental 
Health Services Administration commented on our draft report.  Both concurred with our 
recommendation. 
The Health Care Financing Administration has already initiated several activities that we 
believe will increase compliance with the new Patients Rights Condition of Participation. 
For example, HCFA initiated efforts to educate key players such as State agencies, 
providers, accrediting organizations, and protection and advocacy groups on expected 
changes in treatment policies and procedures.  Further, HCFA has initiated a training 
program for State and HCFA regional surveyors on the new Patients Rights Condition of 
Participation. 
The Substance Abuse and Mental Health Services Administration noted that our study is 
beneficial in that it provides baseline data on compliance with the new Patients Rights 
Condition of Participation, and suggested several issues for further study.  HCFA staff 
made similar comments to us in earlier discussion.  We agree with the suggestion by 
SAMHSA and HCFA that more study is needed on the care and services  provided to 
persons with mental illnesses.  Our present study was one in a continuing series of studies, 
audits, and reviews on services to persons with mental illnesses.  As we continue to 
analyze this subject in the future, we would expect to include coverage of some or all of 
the issues raised by SAMHSA and HCFA. 
Both HCFA and SAMHSA also suggested several technical changes to the report for 
clarification.  We made the changes where the scope of our study and facts obtained 
would support them. 
We provide the full text of comments by both HCFA and SAMHSA in the Appendix. 
3 
Restraints and Seclusion: Policies for Psychiatric Hospitals  OEI-04-99-00150  INTRODUCTION 
PURPOSE 
To describe State policies for restraints and seclusion in psychiatric hospitals. 
BACKGROUND 
According to the 1999 Surgeon Generals Report on Mental Health, over five million 
people experience severe mental illnesses each year.  In 1998, Medicare and Medicaid paid 
almost $6 billion to provide mental health care to over 500,000 beneficiaries in psychiatric 
hospitals.  That care is typically provided in two types of psychiatric hospitals: 
freestanding psychiatric hospitals and psychiatric units within acute care hospitals.  Both 
types can be publicly owned or privately owned. 
For the purpose of this report, public psychiatric hospital refers to State owned 
freestanding psychiatric hospitals and State owned psychiatric units within acute care 
hospitals.  Private psychiatric hospital refers to privately owned freestanding psychiatric 
hospitals and privately owned psychiatric units within acute care hospitals. 
Restraints and Seclusion 
During hospitalization persons with mental illness may be placed in restraints or seclusion 
to prevent them from injuring themselves and others. 
Restraint generally refers to methods for restricting a persons freedom of movement. 
Restraints can be chemical, physical, or mechanical.  Chemical restraint refers to the use of 
drugs to control behavior or restrict a persons freedom of movement.  In such instances, 
the drugs are not considered a part of standard medical or psychiatric treatment for the 
patient.  Physical restraint generally involves restricting a persons movement by physical 
force.  It is typically performed in an emergency to prevent a person from hurting 
themselves or others.  Mechanical restraint generally refers to use of an external device, 
such as straps, belts, or cuffs to restrict a persons freedom of movement. 
Seclusion is generally defined as involuntarily confining a person alone in a room from 
which the person is physically prevented from leaving. 
Concern Over Use of Restraint and Seclusion 
The use of restraints and seclusion may be appropriate in some circumstances, but in 
others it may be inappropriate and abusive.  Generally, the Health Care Financing 
Administrations new Patients Rights Condition of Participation regulations provide for 
the use of restraints and seclusion as an exception rather than normal practice for behavior 
management.  To illustrate, it can be appropriate in emergency situations, but only when 
less restrictive interventions have been determined to be ineffective to ensure 
4 
Restraints and Seclusion: Policies for Psychiatric Hospitals  OEI-04-99-00150  safety of the patient and others.  On the other hand, the regulations show that restraints 
and seclusion are inappropriate when imposed as a means of coercion, discipline, 
convenience, or retaliation by staff. 
In recent years, reports of deaths and injuries resulting from inappropriate use of restraints 
and seclusion have raised serious concerns within the Congress, the Department of Health 
and Human Services, and States.  For example, in September 1999, the General 
Accounting Office reported that 24 deaths associated with the use of restraints and 
seclusion occurred during fiscal year 1998.  Previously, in October 1998, the Hartford 
Courant, a Connecticut newspaper, reported that 142 deaths resulted from inappropriate 
use of restraints in psychiatric facilities from 1988 through 1998 -- an 11 year period. 
Oversight For Use of Restraints and Seclusion 
A variety of State and Federal agencies and private sources provide oversight for patient 
care provided by psychiatric hospitals. 
The Health Care Financing Administration (HCFA) has Federal oversight responsibility for 
the Medicare program.  As such, HCFA establishes Federal requirements for psychiatric 
hospitals to participate in Medicare funded programs.  The requirements are published as 
general and Special Conditions of Participation. 
HCFAs new Patients Rights Condition of Participation became effective as part of the 
Medicare general Condition of Participation in August 1999.  They place two standards on 
all hospitals using restraints and seclusion.  One standard provides guidance for the use of 
restraints during acute medical and surgical care.  The other provides guidance for using 
restraints and seclusion in emergency situations where a patient is violent or aggressive, 
and a danger to himself or others. 
State mental health agencies have front line oversight responsibility for psychiatric 
hospitals.  Generally, State Departments of Mental Health1 have oversight responsibility 
for public psychiatric hospitals.  State Licensure and Certification agencies2 generally have 
oversight responsibility for private psychiatric hospitals.  The State agencies certify that 
both public and private psychiatric hospitals comply with HCFAs general Condition of 
Participation, and applicable State laws and policies.  The certification and licensure 
process authorizes psychiatric hospitals to participate in Medicare funded programs. 
By Federal statute, hospitals accredited by the Joint Commission on the Accreditation of 
Healthcare Organizations are deemed to have met Medicares general Condition of 
Participation.  Of the 611 psychiatric hospitals that participate in the Medicare program, 
1We used a general, common title for various individual State agencies that have oversight responsibility for publicly 
owned and operated psychiatric hospitals. The title for any specific State agency may vary from the common title we used. 
Also, in some States the agency may have responsibility for both the publicly and privately owned psychiatric hospitals. 
2We chose a general, common title to represent the various individual State agencies that have oversight 
responsibility for privately owned and operated psychiatric hospitals. The title for the agency in specific States could be 
different. Also, in some States the agency may have responsibility for both publicly and privately owned psychiatric hospitals. 
5 
Restraints and Seclusion: Policies for Psychiatric Hospitals  OEI-04-99-00150  almost 94 percent (572) were accredited by the Joint Commission in 1999.  The Joint 
Commission surveys its accredited hospitals every 3 years, at a minimum, to ensure they 
continue to comply with established Joint Commission standards, including those for 
restraint and seclusion.  We anticipate that the Joint Commission will revise its standards 
to take into consideration the new Patients Rights Condition of Participation. 
However, neither Joint Commission accreditation, nor State licensure and certification 
alone allow free standing psychiatric hospital participation in the Medicare program.  Free 
standing psychiatric hospitals are also required to meet two Special Conditions of 
Participation -- hospital staffing and medical record documentation.  HCFA contracts with 
psychiatric clinicians to periodically review hospitals for compliance with the two special 
conditions. 
Hospitals are required to document the use of restraints and seclusion in the patients 
medical record.  When HCFAs contracted clinicians find instances of restraint and 
seclusion use, they may initiate further investigation.  However, the HCFA contractor 
surveys are only done about every 3 to 4 years. 
Likewise, the Substance Abuse and Mental Health Administration funds a network of 
State Protection and Advocacy (P&A) organizations that provide oversight for persons 
with mental illness who reside in psychiatric hospitals.  State P&A organizations monitor 
and investigate incidents of inappropriate use of restraint and seclusion. 
METHODOLOGY 
This is one in a series of planned inspections on the use, control, and impact of the use of 
restraints and seclusion in psychiatric hospitals.  In this report, we ascertained what 
policies States had established for using restraints and seclusion in public and private 
psychiatric hospitals.  We also compared State policies to the Health Care Financing 
Administrations new Patients Rights Condition of Participation regulations.  Subsequent 
reports will focus on reporting systems for restraint and seclusion use, and for patient 
abuse and death in psychiatric hospitals. 
Data Collection 
Our findings are based largely on self-reported information provided by State Mental 
Health and Licensing agencies, and Protection and Advocacy organizations.  Using a 
standardized written data collection instrument, we surveyed agencies in all 50 States and 
the District of Columbia that provide policy guidance and oversight for public and private 
psychiatric hospitals.  Likewise, we surveyed Protection and Advocacy organizations in 
each of the 50 States and the District of Columbia. 
We received responses from 43 State Mental Health Departments that provide oversight 
for State owned psychiatric hospitals -- a response rate of 84 percent.  We received 36 
responses from State Licensing and Certification agencies that provide oversight for 
privately owned psychiatric hospitals  -- a response rate of 71 percent.  In some States, 
one agency provided responses for both State and privately owned hospitals.  Finally, 44 
6 
Restraints and Seclusion: Policies for Psychiatric Hospitals  OEI-04-99-00150  State Protection and Advocacy organizations responded to our survey -- a response rate 
of 86 percent.  The Protection and Advocacy organizations responses encompassed both 
State and privately owned psychiatric hospitals. 
We received survey responses from July through September 1999.  This time period 
preceded and overlapped the issuance of the Health Care Financing Administrations final 
version of the new Patients Rights Condition of Participation regulations. 
Therefore, the new standards had not been fully implemented by States at the time of our 
inspection.  However, where possible we compared existing State policies to the new 
Patients Rights Condition of Participation regulations.  As a result, our study provides an 
early snapshot of State policies at the time the new Patients Rights Condition of 
Participation became effective.  This snapshot provides a baseline for measuring progress 
in implementing the new requirements, and insight into policies that need special attention 
in the early stages of implementation. 
We did not audit the self-reported information.  However, we supplemented and 
corroborated it through interviews with officials and staff in a variety of Federal and State 
agencies, advocacy and trade organizations, and psychiatric hospitals.  To illustrate, we 
interviewed officials and staff from the following organizations: 
<  The Health Care Financing Administration,

<  Substance Abuse and Mental Health Services Administration,

<  State Departments of Mental Health,

<  State Licensing and Certification agencies,

<  State Protection and Advocacy organizations,

<  National Association of Protection and Advocacy Systems,

<  National Association of State Mental Health Program Directors,

<  National Alliance for the Mentally Ill, and 

<  Public and private psychiatric hospitals. 

Additionally, we conducted document and literature searches.  We analyzed State laws, 
regulations, and policies on the use of restraints and seclusion.  We also reviewed 
professional trade journals and publications, and audit and evaluation reports on the use of 
restraints and seclusion in psychiatric hospitals. 
Data Analysis 
We integrated and synthesized data from various sources, identifying common 
characteristics and major differences.  Additionally, we compared the policies in public and 
private psychiatric hospitals. 
____  ____  ____  ____ 
We conducted this inspection in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency. 
7 
Restraints and Seclusion: Policies for Psychiatric Hospitals  OEI-04-99-00150  FINDINGS 
Initiating Restraints and Seclusion 
HCFAs New Patients Rights Condition of Participation 
HCFAs new Patients Rights Condition of Participation requires all hospital staff who 
have direct patient contact to have on-going education and training in the proper use of 
restraint and seclusion application and techniques.  The regulation also requires education 
and training in alternative methods for avoiding the use of restraint and seclusion. 
State Policies 
State policies generally specify who can initiate a restraint or seclusion.  Most State 
policies for both public and private psychiatric hospitals required a nurse or physician to 
initiate a restraint or seclusion.  Over 74 percent of the States restricted authority to a 
nurse or doctor for initiating a restraint or seclusion in public psychiatric hospitals, and 73 
percent have the same restriction for private hospitals. 
Table 1 
Initiating Restraints and Seclusion 
Who Can Initiate  State Policies For Public  State Policies For 
Hospitals  Private Hospitals 
Nurse or Physician  29  74.4%  19  73.1% 
Hospital Policy  8  20.5%  7  26.9% 
Unknown  2  5.1%  0  0.0% 
Subtotal  39  100.0%  26  100.0% 
No Answer  4  9.3%  10  27.8% 
Total  43  36 
As Table 1 shows, 21 percent of the States allowed each public psychiatric hospital to 
establish who was authorized to restrain or seclude a patient.  Likewise, 27 percent of the 
States allowed private psychiatric hospitals to set their own policy.  In such States, the 
policies did not prescribe who was authorized to restrain or seclude a patient.  These 
States allowed hospitals to use any trained, authorized, or qualified staff.  One State 
policy for private psychiatric hospitals allowed anyone to restrain or seclude a patient in 
an emergency situation. 
8 
Restraints and Seclusion: Policies for Psychiatric Hospitals  OEI-04-99-00150  The Protection and Advocacy staff we interviewed generally expressed concern about 
such policies.  They expressed a belief that allowing someone other than a physician or 
nurse to initiate a restraint or seclusion increased the risk that it may be unnecessary or 
inappropriate.  Mental health advocates told us that one of the most dangerous moments 
for restrained patients is during the take-down.  A take-down refers to when a patient is 
forced down and immobilized for application of a restraint.  It is during this quick, often 
frantic, period that a patient can sustain serious injury and even death.  The Hartford 
Courant reported that 23 of 142 restraint-related deaths occurred while patients were 
being restrained in face-down floor holds. 
Hospital officials and staff we interviewed told us, however, that in an emergency, the 
patient and others could be in danger.  Therefore, they said it is often necessary for the 
closest employee to restrain a patient until other trained staff arrive. 
Physician Orders 
HCFAs New Patients Rights Condition of Participation 
HCFAs new Patients Rights Condition of Participation requires that a physician or other 
licensed independent practitioner see and evaluate the need for restraint and seclusion 
within 1 hour after the initiation of this intervention. 
State Policies 
As Table 2 shows, the policy in 27 percent of the States required that public psychiatric 
hospitals immediately obtain a physician order when a patient is restrained or secluded. 
Only 16 percent of the States had a similar requirement for private hospitals.  Seventy 
eight  percent of the States required public psychiatric hospitals to obtain physician orders 
within one hour of initiating a restraint or seclusion.  For private psychiatric hospitals, 60 
percent of States had the same one hour requirement. 
However, only 2 State policies required their public hospitals to meet the see and 
evaluate requirement. None did so for private hospitals.  The other States allowed 
physician orders for restraints and seclusion to be given over the telephone. 
Also, 8 percent of the States allowed public hospitals in excess of one hour to obtain a 
physician order after a patient had been restrained or secluded.  In contrast, 16 percent of 
the States allowed in excess of one hour for private psychiatric hospitals to obtain a 
physician order after a patient had been restrained or secluded.  Of the States that allowed 
over one hour, one allowed public psychiatric hospitals, and two allowed private 
psychiatric hospitals, more than 24 hours to obtain the required physician order. 
9 
Restraints and Seclusion: Policies for Psychiatric Hospitals  OEI-04-99-00150  Table 2 
Time Requirements For Obtaining Physician Orders 
Time Period Options  State Policies For Public  State Policies For Private 
Hospitals  Hospitals 
Immediately  10  27.0%  4  16.0% 
Within 15 minutes  2  5.4%  1  4.0% 
16-30 minutes  4  10.8%  1  4.0% 
31-60 minutes  13  35.1%  9  36.0% 
1 to 8 hrs  2  5.4%  2  8.0% 
Over 8 hrs  1  2.7%  2  8.0% 
Hospital Policy  2  5.4%  5  20.0% 
Not specified  3  8.1%  1  4.0% 
Subtotal  37  100.0%  25  100.0% 
No Answer  6  14.0%  11  30.6% 
Total  43  36 
Views of Provider and Advocacy Groups 
In their response to HCFAs new Patients Rights Condition of Participation interim final 
rule, physician and hospital groups, such as the American Hospital Association, the 
National Association of Psychiatric Health Systems, and the American Psychiatric 
Association, expressed concern about the new one hour see and evaluate requirement. 
The groups expressed concern that requiring a face-to-face evaluation will increase costs 
and may be difficult for rural and private psychiatric hospitals to implement.  The groups 
also believe that the requirement inappropriately dictates medical practice. 
The mental health advocates from the State Protection and Advocacy system and National 
Alliance for the Mentally Ill stressed the importance of a face-to-face physician evaluation 
before, or at a minimum immediately after, placing a patient in restraint or seclusion. 
Requiring a physician to see and evaluate a patient before issuing an order, or 
immediately after restraint or seclusion, allows the physician to determine if the restraints 
or seclusion is warranted, or if another form of intervention is appropriate.  Further, in 
situations where a physician determines that restraint or seclusion is appropriate, the 
physician can then determine that it is properly applied. 
Another reason the advocates gave for requiring a physician to immediately evaluate a 
patient that has been restrained or secluded is that it allowed the physician to quickly 
provide needed medical treatment for any injuries sustained during the restraint procedure. 
The Hartford Courant series of articles emphasized the importance of early medical 
attention to any injuries incurred during a restraint process.  For example, one article 
described a situation where an 11-year-old boy died as a result of a crushed chest 
sustained during the restraint process.  Hospital staff who restrained the boy ignored his 
complaints of injury.  The boy was dead before a physician ever examined him. 
10 
Restraints and Seclusion: Policies for Psychiatric Hospitals  OEI-04-99-00150  Time Limits 
HCFAs New Patients Rights Condition of Participation 
HCFAs new Patients Rights Condition of Participation limits the duration of each 
written restraint or seclusion order to 4 hours for adults, 2 hours for adolescents age 9 to 
17, and 1 hour for children under age nine.  Original orders may be renewed for up to a 
total of 24 hours before requiring a second face-to-face physician or licensed independent 
practitioner evaluation. 
State Policies 
The State policies in 43 percent of the States limited restraint and seclusion orders in 
public psychiatric hospitals to between 1 and 4 hours in duration.  Conversely, only 9 
percent of the States had a similar limit for restraint and seclusion orders in private 
psychiatric hospitals.  Table 3 shows State policies for time limits on restraints and 
seclusion for both public and private psychiatric hospitals. 
As Table 3 shows, 11 percent of the States did not establish physician order time limits for 
public psychiatric hospitals.  Almost 35 percent of the States did not establish physician 
order time limits for private psychiatric hospitals.  In such instances, the hospitals 
established their own policies. 
Table 3 
Requirements on the Duration of Restraint and Seclusion Orders 
Time Limits  State Policies For Public  State Policies For Private 
Hospitals  Hospitals 
1-4 hours  15  42.9%  2  8.7% 
5-14 hours  4  11.4%  6  26.1% 
24 hours  8  22.9%  5  21.7% 
Hospital Policy  4  11.4%  8  34.8% 
Unknown  4  11.4%  2  8.7% 
Subtotal  35  100.0%  23  100.0% 
No Answer  8  18.6%  13  36.1% 
Total  43  36 
Seven of the 15 States told us their State policy varied between 1and 4 hours in duration 
for physician orders in public psychiatric hospitals.  The time limits varied depending on a 
patients age.  All seven State policies were identical to the new Condition of 
Participation:  4 hours for adults, 2 hours for adolescents 9 to 17 years of age, and 1 hour 
for children under 9 years of age.  None of the State policies for private hospitals made 
this distinction. 
11 
Restraints and Seclusion: Policies for Psychiatric Hospitals  OEI-04-99-00150  The mental health professionals we interviewed agreed that restraint and seclusion 
physician orders should be time limited.  They said patients should be frequently evaluated 
and released as soon as possible.  The importance of this guidance was emphasized by the 
Hartford Courant article that related a death to a lengthy restraint.  In that instance, a 38 
year-old man died from medical complications after being restrained to a bed for 18 hours. 
Such adverse outcomes highlight the importance of frequently evaluating patients who are 
restrained or secluded.  A short time limit on restraint and seclusion physician orders 
requires frequent oversight and evaluation of patients. 
Patient Monitoring 
HCFAs New Patients Rights Condition of Participation 
HCFAs new Patients Rights Condition of Participation requires continual (close, 
recurring) assessment, monitoring, and reevaluation of patients that are either restrained or 
secluded.  However, for persons that are both restrained and secluded the Condition of 
Participation requires continuous (constant) monitoring face-to-face by an assigned staff 
or by staff using both audio and video equipment. 
State Policies 
As Table 4 shows, eighty five percent of public psychiatric hospitals, and 48 percent of 
private psychiatric hospitals meet the continual (close, recurring) standard of the new 
Patients Rights Condition of Participation by requiring patient monitoring every 15 
minutes or less.  Four States had a higher standard of monitoring than the new Patients 
Rights Condition of Participation by requiring continuous (constant) monitoring for 
patients in public psychiatric hospitals.  One State did so for private psychiatric hospitals. 
One State allowed patient monitoring in both public and private psychiatric hospitals on 
two hour intervals.  In addition, one State had no specific policy on frequency of 
monitoring for restrained and secluded patients in private psychiatric hospitals. 
12 
Restraints and Seclusion: Policies for Psychiatric Hospitals  OEI-04-99-00150  Table 4 
Requirements for Frequency of Monitoring 
State Policies For Public  State Policies For Private 
Time Periods  Hospitals  Hospital 
Continuous  4  10.0%  1  3.7% 
15 minutes  30  75.0%  12  44.4% 
30 minutes  0  0.0%  2  7.4% 
1 hour  2  5.0%  2  7.4% 
2 hours  1  2.5%  1  3.7% 
Unknown  2  5.0%  2  7.4% 
Hospital Policy  1  2.5%  6  22.2% 
No Policy  0  0.0%  1  3.7% 
Subtotal  40  100.0%  27  100.0% 
No Answer  3  7.0%  9  25.0% 
Total  43  36 
The type and frequency of monitoring is important for the safety of persons in restraints or 
seclusion.  To illustrate, improperly applied restraints that are harmful to patients may go 
undetected unless patients are adequately monitored.  One such example was related to us 
by a State Protection and Advocacy organization.  They described an incident where a 
nurses aide restrained a 45 year-old woman to her bed at about 8:30 p.m. without a 
physicians order.  The aide had not been trained in applying restraints.  The woman was 
left restrained and unchecked overnight.  Almost 10 hours later, she was found dead on 
the floor with the restraints bunched around her neck and chest. 
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Restraints and Seclusion: Policies for Psychiatric Hospitals  OEI-04-99-00150  RECOMMENDATION 
Many State policies already met some of the new Patients Rights Condition of Participation 
standards.  However, other State policies for both public and private psychiatric hospitals did not. 
State policies for use of restraints and seclusion in private psychiatric hospitals more frequently 
fell short of the new standards. 
Therefore, we recommend that HCFA work aggressively with States and accreditation 
organizations to quickly raise psychiatric hospital compliance with the new Patients 
Rights Condition of Participation where necessary.  Particular attention should be 
given to policies for private psychiatric hospitals. 
14 
Restraints and Seclusion: Policies for Psychiatric Hospitals  OEI-04-99-00150  AGENCY  COMMENTS 
Both the Health Care Financing Administration and the Substance Abuse and Mental Health 
Services Administration commented on our draft report.  Both concurred with our 
recommendation. 
The Health Care Financing Administration has already initiated several activities that we believe 
will increase compliance with the new Patients Rights Condition of Participation.  For example, 
HCFA initiated efforts to educate key players such as State agencies, providers, accrediting 
organizations, and protection and advocacy groups on expected changes in treatment policies and 
procedures.  Further, HCFA has initiated a training program for State and HCFA regional 
surveyors on the new Patients Rights Condition of Participation. 
The Substance Abuse and Mental Health Services Administration noted that our study is 
beneficial in that it provides baseline data on compliance with the new Patients Rights Condition 
of Participation, and suggested several issues for further study.  HCFA staff made similar 
comments to us in earlier discussion.  We agree with the suggestion by SAMHSA and HCFA that 
more study is needed on the care and services provided to persons with mental illnesses.  Our 
present study was one in a continuing series of studies, audits, and reviews on services to persons 
with mental illnesses.  As we continue to analyze this subject in the future, we would expect to 
include coverage of some or all of the issues raised by SAMHSA and HCFA. 
Both HCFA and SAMHSA also suggested several technical changes to the report for 
clarification.  We made the changes where the scope of our study and facts obtained  would 
support them. 
We provide the full text of comments by both HCFA and SAMHSA in the Appendix. 
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Restraints and Seclusion: Policies for Psychiatric Hospitals  OEI-04-99-00150  APPENDIX 
Agency Comments 
Health Care Financing Administration (HCFA)

Substance Abuse and Mental Health Services Administration (SAMHSA)

. 

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Finally, HCFA continues to search for ways to keep SAs and accreditation organization current with our 
expectations. We are exploring the use of a web site, conference calls, and satellite broadcasts to better 
reach SAs and accreditation organizations. 
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