Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JUNE GIBBS BROWN 

Inspector General 

AUGUST 2000 

OEI-04-99-00150 

RESTRAINTS AND SECLUSION 

State Policies 

for 

Psychiatric Hospitals 
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 

JUNE GIBBS BROWN 

Inspector General 

AUGUST 2000 

OEI-04-99-00150 

RESTRAINTS AND SECLUSION 

State Policies 

for 

Psychiatric Hospitals 
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 Administration’s 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 

Restraints and Seclusion: Policies for Psychiatric Hospitals 1 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 Administration’s 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 Administration’s 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 Administration’s 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 Administration’s 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 Administration’s 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. 

Restraints and Seclusion: Policies for Psychiatric Hospitals 2 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. 

Restraints and Seclusion: Policies for Psychiatric Hospitals 3 OEI-04-99-00150 
INTRODUCTION 

PURPOSE 

To describe State policies for restraints and seclusion in psychiatric hospitals. 

BACKGROUND 

According to the 1999 Surgeon General’s 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 person’s freedom of movement. 

Restraints can be chemical, physical, or mechanical. Chemical restraint refers to the use of 

drugs to control behavior or restrict a person’s 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 person’s 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 person’s 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 

Administration’s 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 

Restraints and Seclusion: Policies for Psychiatric Hospitals 4 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. 

HCFA’s 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 HCFA’s 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 Medicare’s general Condition of 

Participation. Of the 611 psychiatric hospitals that participate in the Medicare program, 

1

We 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. 

2

We 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. 

Restraints and Seclusion: Policies for Psychiatric Hospitals 5 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 patient’s 

medical record. When HCFA’s 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 

Administration’s 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 

Restraints and Seclusion: Policies for Psychiatric Hospitals 6 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 Administration’s 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 President’s Council on Integrity and Efficiency. 

Restraints and Seclusion: Policies for Psychiatric Hospitals 7 OEI-04-99-00150 
FINDINGS 

Initiating Restraints and Seclusion 

HCFA’s New Patients’ Rights Condition of Participation 

HCFA’s 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 

Hospitals 

State Policies For 

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. 

Restraints and Seclusion: Policies for Psychiatric Hospitals 8 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 

HCFA’s New Patients’ Rights Condition of Participation 

HCFA’s 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. 

Restraints and Seclusion: Policies for Psychiatric Hospitals 9 OEI-04-99-00150 
Table 2 

Time Requirements For Obtaining Physician Orders 

Time Period Options State Policies For Public 

Hospitals 

State Policies For Private 

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 HCFA’s 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. 

Restraints and Seclusion: Policies for Psychiatric Hospitals 10 OEI-04-99-00150 
Time Limits 

HCFA’s New Patients’ Rights Condition of Participation 

HCFA’s 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 

Hospitals 

State Policies For Private 

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 

patient’s 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. 

Restraints and Seclusion: Policies for Psychiatric Hospitals 11 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 

HCFA’s New Patients’ Rights Condition of Participation 

HCFA’s 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. 

Restraints and Seclusion: Policies for Psychiatric Hospitals 12 OEI-04-99-00150 
Table 4 

Requirements for Frequency of Monitoring 

Time Periods Hospitals 

State Policies For Public 

Hospital 

State Policies For Private 

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 

physician’s 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. 

Restraints and Seclusion: Policies for Psychiatric Hospitals 13 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. 

Restraints and Seclusion: Policies for Psychiatric Hospitals 14 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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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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