Physical Restraint: CMS Rules and Compliance

Q: What are some physical restraints?

Physical restraints include manual holds applied by staff, limb holders (wrist and ankle straps), mitten restraints secured to prevent arm movement, vest and jacket holders, enclosure canopy beds, and raising all four side rails on an adult hospital bed to prevent egress.

Q: When may you use physical restraint?

Physical restraint may only be used when necessary to ensure the immediate physical safety of the patient, staff, or others, and only after less restrictive alternatives have been attempted and determined ineffective. Restraints may never be used for discipline, staff convenience, punishment, or coercion.

Q: What is the difference between mechanical and physical restraints?

Physical (manual) restraints involve direct human force to contain a patient, whereas mechanical restraints use manufactured equipment, straps, or cuffs. Under CMS 42 CFR § 482.13, both are regulated under a single restraint standard requiring provider orders, close monitoring, and documentation.

Q: What are some examples of physical restraints used in nursing care?

Common nursing examples include bilateral soft wrist restraints to prevent accidental extubation in intensive care, padded mitts to protect vascular lines from dislodgement, and locked geriatric chair trays to prevent dangerous unassisted falls in patients with severe dementia.

Q: Who is the only member of the interdisciplinary team that can obtain an order for restraint usage?

In hospital interdisciplinary teams, the Registered Nurse (RN) is the professional team member with the clinical scope to evaluate the patient, initiate emergency intervention, and obtain the authorized restraint order from the attending provider.

Q: Are PRN orders permitted for physical restraints?

No. Under CMS 42 CFR § 482.13(e)(5), PRN (as-needed) orders for physical restraints are strictly prohibited. Each restraint episode requires a distinct, time-limited clinical order based on real-time evaluation.

General regulatory and compliance guidance for healthcare administrators, compliance officers, and nursing leadership. This guide does not constitute medical advice or clinical procedure instructions.

What It Is and Who Runs It

A physical restraint is any manual method, physical or mechanical device, material, or equipment attached or adjacent to a patient’s body that the individual cannot easily remove and that restricts freedom of movement or normal access to one’s body. In Medicare- and Medicaid-certified healthcare facilities across the United States, physical restraint usage is governed by the Centers for Medicare & Medicaid Services (CMS). Federal baseline requirements are codified in the Conditions of Participation for Hospitals at 42 CFR § 482.13(e) and interpreted in CMS State Operations Manual (SOM) Appendix A under survey tags A-0154 through A-0214.

Compliance oversight is conducted by state survey agencies and deeming accreditation organizations, including The Joint Commission under its Comprehensive Accreditation Manual for Hospitals (CAMH). Federal regulations mandate that every patient has the right to be free from physical or mental abuse, corporal punishment, and any restraint or seclusion imposed by staff for coercion, discipline, convenience, or retaliation.

What Is the Difference Between Mechanical and Physical Restraints?

In clinical practice, staff distinguish between manual holds and manufactured hardware:

Physical (Manual) Restraints: Direct physical force applied by personnel to contain a patient’s limbs or torso without mechanical hardware, such as manual holds during acute behavioral crises.
Mechanical Restraints: Manufactured equipment or straps secured to a patient’s body to limit mobility, such as soft limb holders, vest restraints, and locked enclosure beds.

Under 42 CFR § 482.13(e)(1)(i), CMS unifies both forms under one restraint definition, requiring clinical necessity, provider orders, prohibition of PRN authorizations, and documented failure of less restrictive alternatives. Manufactured physical restraints are separately regulated by the FDA as Class I devices under 21 CFR § 880.6760, as detailed in our guide to medical restraints, whereas medication-based restriction is governed under CMS rules for chemical restraint.

Eligibility and Regulatory Scope

The federal restraint standard applies to all acute care, critical access, and psychiatric hospitals certified by Medicare or Medicaid. Under 42 CFR § 482.13(e)(1)(i), CMS explicitly excludes specific clinical devices and practices from the restraint definition when used for standard medical care:

Orthopedically prescribed appliances, surgical dressings, and protective bandages.
Protective helmets used to prevent head injury during seizures.
Standard surgical positioning devices and physical immobilization during clinical procedures.
Brief physical holding without resistance to conduct routine medical examinations or tests.
Physical escorts, defined as temporarily touching or holding a patient’s hand or arm to assist them in walking safely.
Safety devices such as wheelchair lap belts that a patient can voluntarily release without assistance.

When safety devices such as bed rails or chair lap trays are configured so that an impaired patient cannot remove them and cannot leave the bed or chair, CMS classifies them as mechanical restraints.

What It Requires: Standards for Physical Restraint

CMS classifies physical restraint as an intervention of last resort. Staff may only initiate restraint when necessary to protect the immediate physical safety of the patient, staff, or others, and only after less restrictive interventions have proven ineffective. Federal rules establish two distinct operational pathways:

Non-Violent (Acute Medical/Surgical) Restraint: Implemented to protect life-sustaining medical equipment (such as endotracheal tubes or central lines) from accidental dislodgement by a confused patient.
Violent or Self-Destructive Behavioral Restraint: Implemented in response to acute, severely combative, aggressive, or self-harming behavior posing an immediate danger to physical safety.

What Are Some Physical Restraints?

Physical restraints used across healthcare facilities include manual holds by trained staff, limb restraints (soft foam wrist or ankle straps fastened to the movable bed frame), mitten restraints secured to prevent arm movement, vest and jacket holders secured around the torso (such as devices examined in our review of what is a Posey vest), enclosure beds featuring zippered mesh netting, and elevating all four side rails on an adult hospital bed to prevent egress.

What Are Some Examples of Physical Restraints Used in Nursing Care?

Typical nursing applications under the non-violent medical track include:

Applying bilateral soft wrist restraints to an intubated critical care patient who reflexively reaches for their endotracheal tube.
Placing a soft mitten restraint on the dominant hand of a delirious patient repeatedly pulling at a dialysis catheter.
Locking a lap tray on a geriatric chair to immobilize an unsteady patient with advanced dementia who repeatedly attempts unassisted transfers.

Nursing teams must trial restraint alternatives before applying physical devices. Sourced alternatives include pressure-sensor monitors, as evaluated in our guide to chair alarm devices, low beds paired with bedside mats as reviewed in our analysis of fall mat safety, one-on-one sitters, and frequent reorientation.

Clinical Compliance Steps and Documentation

To comply with CMS Conditions of Participation, clinical teams must adhere to a structured protocol:

Who Is the Only Member of the Interdisciplinary Team That Can Obtain an Order for Restraint Usage?

In interdisciplinary hospital care teams, the Registered Nurse (RN) is the designated professional team member qualified to assess the patient, initiate emergency holds when imminent danger exists, and contact the provider to obtain the authorized order. Physical therapists, occupational therapists, and nursing assistants cannot obtain or initiate restraint orders. Only an attending physician or authorized licensed independent practitioner (LIP) may order physical restraint. Under 42 CFR § 482.13(e)(5), “as-needed” or PRN orders for restraint are strictly prohibited.

Required Workflow Steps

Trial Less Restrictive Alternatives: Attempt verbal calming, environmental adjustment, or sitter observation, and document the patient response.
Clinical Assessment: The Registered Nurse evaluates the immediate safety threat and determines whether medical/surgical or behavioral criteria apply.
Obtain Provider Order: Contact the physician or LIP immediately. The order must detail the clinical rationale, device type, location, duration, and measurable discontinuation criteria.
Notify Patient and Family: Inform the patient or healthcare proxy regarding the clinical justification for restraint.
Monitoring and Timely Discontinuation: Carry out interval assessments and release the restraint at the earliest possible time once discontinuation criteria are met.

Restraint Documentation Example

Clinical records must provide objective, time-stamped details rather than subjective impressions:

“02:15 — Patient with acute delirium pulling at endotracheal tube despite verbal redirection and unanchored soft mitts. Sitter observation attempted for 20 minutes without reduction in reaching behavior. Imminent risk of extubation identified. At 02:18, bilateral soft wrist restraints applied to movable bed frame with two-finger slack. Quick-release ties secured. Dr. Perez notified at 02:20; verbal order received for bilateral soft wrist restraints due to extubation risk, duration 24 hours. Radial pulses palpable 2+ bilaterally, capillary refill under 2 seconds, skin warm and intact. Discontinuation criteria: Patient calm, following commands, no reaching for lines. At 04:00, restraints released for range of motion, skin inspection, and hygiene. Intact skin verified; restraints reapplied at 04:15 as reaching resumed.”

Typical Timeline Phases and Monitoring

CMS standards define clear time-limited phases and monitoring intervals based on clinical indication.

What Aspects of Care Will Change for Patients Who Are in Non Violent Restraints?

When a patient is managed under the non-violent medical/surgical restraint pathway rather than the violent behavioral pathway, care protocols shift in several key ways:

No Mandatory 1-Hour Face-to-Face Evaluation: Federal rules do not require an in-person physician evaluation within 1 hour for medical/surgical restraints, provided a timely order is secured per hospital policy.
Longer Renewal Intervals: Non-violent restraint orders may remain active for up to 24 hours before requiring renewal, avoiding the 4-hour behavioral renewal cap.
Physiological Care Focus: Bedside monitoring emphasizes limb circulation, pulse checks, skin integrity, and periodic two-hour release for range of motion and repositioning.
Category Transition Vigilance: If a medical patient exhibits acute physical violence, staff must immediately transition care to the violent restraint protocol, initiating the 1-hour physician evaluation.

Monitoring in Violent or Self-Destructive Restraints

Under 42 CFR § 482.13(e)(3)–(12), behavioral restraints require strict compliance checkpoints: an in-person face-to-face evaluation by a physician, LIP, or trained RN within 1 hour; order duration limits capped at 4 hours for adults aged 18 and older, 2 hours for children aged 9 to 17, and 1 hour for children under 9; mandatory in-person provider re-evaluation after 24 cumulative hours; and continuous observation by trained staff.

Common Compliance Mistakes

CMS audit findings highlight recurring deficiencies in hospital restraint management:

Authorizing PRN Orders: Writing “restraints as needed for agitation” is an explicit federal violation.
Omitting Alternative Trials: Failing to document prior trials and failure of less restrictive alternatives in the medical record.
Missed 1-Hour Evaluations: Failing to complete or document the required in-person evaluation within 1 hour during behavioral restraint episodes.
Infrequent Bedside Releases: Neglecting documented two-hour releases for skin checks, circulation assessments, and range of motion.
Attaching Straps to Movable Bed Rails: Tying restraint ties to side rails creates dangerous crush or strangulation risks during bed adjustments.
Failure to Report Deaths: Under 42 CFR § 482.13(g), hospitals must report to CMS any death occurring while a patient is in restraints, within 24 hours of removal, or reasonably linked to restraint use by the close of the next business day.

Hospital restraint programs operate across multiple overlapping standards, summarized below as described in official guidelines accessed on November 7, 2026:

Regulatory Body / Standard	Primary Scope	Ordering Authority	Order Limit	Oversight & Reporting
CMS 42 CFR § 482.13(e) (Non-Violent)	Acute medical/surgical care (protecting lines and devices)	Physician or authorized licensed practitioner	Up to 24 hours per facility policy	State survey agency inspection; hospital QAPI review
CMS 42 CFR § 482.13(e) (Violent)	Emergency control of combative or self-destructive behavior	Physician or authorized licensed practitioner	4h (adults), 2h (ages 9–17), 1h (<9)	1-hour face-to-face evaluation; § 482.13(g) death reporting
The Joint Commission (CAMH PC Standards)	Accreditation compliance across healthcare organizations	Privileged licensed independent practitioner	Aligned with CMS limits (4h/2h/1h/24h)	Sentinel event reporting for restraint-associated harm
FDA 21 CFR § 880.6760 (Protective Restraints)	Manufacturing and commercial labeling of restraint devices	Prescription labeling and manufacturer IFU	Device lifespan specifications	Medical Device Reporting (21 CFR Part 803)

Frequently Asked Questions

What are some physical restraints?