Restraint and Seclusion Under the CMS Conditions of Participation (42 CFR 482.13)

Restraint and seclusion in Medicare-participating hospitals are governed by 42 CFR 482.13(e), a standard within the Patient’s Rights Condition of Participation, with staff training requirements at 482.13(f) and death reporting at 482.13(g). The regulation is unusually prescriptive for a Condition of Participation: it sets order time limits by patient age, mandates a face-to-face evaluation within one hour for one category of use, defines what does and does not count as a restraint, and requires certain deaths to be reported to CMS by the close of the next business day.

Almost every practical question about restraint compliance reduces to a single determination made at the bedside: is this use for the management of violent or self-destructive behaviour, or is it a non-violent restraint applied to protect a patient’s physical safety? The two categories share the same underlying rights language but diverge sharply on order renewal, face-to-face evaluation and monitoring. Getting that determination wrong is the most common way a compliant-looking restraint episode becomes a deficiency.

The governing principle

The standard opens with a statement of right, not a procedure:

“All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.”

Three limits follow directly from that sentence and are restated as separate requirements:

• 482.13(e)(2) — restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member or others from harm.
• 482.13(e)(3) — the type or technique used must be the least restrictive intervention that will be effective.
• 482.13(e)(9) — restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order.

That last clause is worth reading twice. An order authorising four hours does not authorise four hours of restraint; it sets a ceiling. Continuing a restraint because the order has not expired is a violation of (e)(9) even when the order itself was valid.

What counts as a restraint

The definitions at 482.13(e)(1) are the starting point for most determinations.

A restraint is:

• any manual method, physical or mechanical device, material, or equipment that immobilises or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or
• a drug or medication when it is used as a restriction to manage the patient’s behaviour or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.

A restraint does not include “devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort).”

Seclusion is “the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving.” The regulation then adds a hard limit that does not apply to restraint: seclusion may only be used for the management of violent or self-destructive behaviour. There is no such thing as a compliant non-violent seclusion under this standard.

The drug-as-restraint determination

The chemical-restraint definition is a two-part test and both parts must be satisfied. A medication is a restraint only if it is used to manage behaviour or restrict movement and it is not standard treatment or dosage for the patient’s condition. A standard dose of an antipsychotic given to treat the psychiatric condition it is indicated for is treatment; the same drug given outside its standard use to subdue a patient is a restraint and triggers the entire apparatus of orders, monitoring, face-to-face evaluation and documentation. This determination is clinical, must be defensible from the record, and is a recurring survey focus.

Physical holding, and the escort carve-out

Physical holding for the purpose of conducting a routine examination or test is excluded from the definition. The parenthetical at the end of the exclusion — “this does not include a physical escort” — is doing real work: escorting a patient is treated separately from the excluded holds, and the exclusion should not be read as blanket permission for staff to physically move a resisting patient.

Orders

The order requirements are set out at 482.13(e)(4)–(8).

• Use must be in accordance with a written modification to the patient’s plan of care, and implemented using safe and appropriate techniques as determined by hospital policy in accordance with state law.
• Use must be in accordance with the order of a physician or other licensed practitioner who is responsible for the patient’s care and is authorised to order restraint or seclusion by hospital policy in accordance with state law.
• Orders must never be written as a standing order or on an as-needed (PRN) basis.
• The attending physician must be consulted as soon as possible if the attending did not order the restraint or seclusion.

Order time limits — violent or self-destructive behaviour

Unless superseded by more restrictive state law, each order for restraint or seclusion used to manage violent or self-destructive behaviour that jeopardises the immediate physical safety of the patient, a staff member or others may only be renewed within the following limits, for up to a total of 24 hours:

Patient age	Maximum order duration before renewal
Adults, 18 years of age or older	4 hours
Children and adolescents, 9 to 17 years of age	2 hours
Children under 9 years of age	1 hour

After 24 hours, before writing a new order, a physician or other licensed practitioner responsible for the patient’s care and authorised to order restraint or seclusion must see and assess the patient. Note the structure carefully: the age-based limits govern renewal within a 24-hour window; the in-person assessment requirement is what gates continuation beyond that window.

Order time limits — non-violent restraint

By contrast, 482.13(e)(8)(iii) provides simply that “each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy.” There is no federal clock. The hospital’s own policy sets the renewal interval — which means the policy itself becomes the compliance standard a surveyor measures against, and a policy that is silent leaves the hospital with no defensible interval at all.

The 1-hour face-to-face evaluation

This requirement, at 482.13(e)(12), applies only to restraint or seclusion used for the management of violent or self-destructive behaviour that jeopardises immediate physical safety. It does not apply to non-violent restraint.

The patient must be seen face-to-face within 1 hour after the initiation of the intervention, by either:

• a physician or other licensed practitioner; or
• a registered nurse who has been trained in accordance with the training requirements at 482.13(f).

The evaluation must assess four things, all four of which are named in the regulation and all four of which belong in the documentation:

1. the patient’s immediate situation;
2. the patient’s reaction to the intervention;
3. the patient’s medical and behavioural condition; and
4. the need to continue or terminate the restraint or seclusion.

Two follow-on rules matter operationally. First, 482.13(e)(13) confirms that states are free to impose more restrictive requirements than (e)(12)(i) — a number of states restrict who may perform the evaluation, and the federal permission for a trained RN is not self-executing everywhere. Second, 482.13(e)(14): where a trained RN performs the evaluation, that RN must consult the attending physician or other licensed practitioner responsible for the patient’s care as soon as possible after completing the 1-hour evaluation. The nurse-performed pathway is a two-step process, and the consultation step is frequently the one missing from the record.

Monitoring

Under 482.13(e)(10), the condition of a restrained or secluded patient must be monitored by a physician, other licensed practitioner, or trained staff who have completed the 482.13(f) training, at an interval determined by hospital policy. As with non-violent order renewal, the federal rule delegates the interval and then holds the hospital to whatever it wrote.

Simultaneous restraint and seclusion is addressed separately at 482.13(e)(15). All requirements of the standard apply, and simultaneous use is permitted only if the patient is continually monitored, either:

• face-to-face by an assigned, trained staff member; or
• by trained staff using both video and audio equipment, with the monitoring in close proximity to the patient.

“Both video and audio” and “in close proximity” are literal requirements — remote video-only observation from a central station does not satisfy this paragraph.

Documentation

482.13(e)(16) lists five items that must appear in the medical record whenever restraint or seclusion is used:

1. the 1-hour face-to-face medical and behavioural evaluation, if restraint or seclusion was used to manage violent or self-destructive behaviour;
2. a description of the patient’s behaviour and the intervention used;
3. alternatives or other less restrictive interventions attempted, as applicable;
4. the patient’s condition or symptoms that warranted the use of restraint or seclusion; and
5. the patient’s response to the interventions used, including the rationale for continued use.

Item 3 is the documentary counterpart of the (e)(2) least-restrictive requirement, and item 5’s rationale-for-continued-use clause is the counterpart of the (e)(9) earliest-discontinuation requirement. A record that documents the restraint but not the alternatives tried and not the reason it continued fails the documentation standard even where the clinical care was appropriate.

Staff training — 482.13(f)

The training standard opens by framing training as a patient right: “The patient has the right to safe implementation of restraint or seclusion by trained staff.”

Training intervals

Staff must be trained and able to demonstrate competency in application of restraints, implementation of seclusion, monitoring, assessment and care of a restrained or secluded patient:

• before performing any of those actions;
• as part of orientation; and
• subsequently on a periodic basis consistent with hospital policy.

Note that the federal rule does not set an annual retraining interval — it delegates the periodicity to hospital policy. Accreditors and states often do set one.

Required training content

The hospital must require appropriate staff to have education, training and demonstrated knowledge based on the specific needs of the patient population, in at least:

• techniques to identify staff and patient behaviours, events and environmental factors that may trigger circumstances requiring restraint or seclusion;
• the use of non-physical intervention skills;
• choosing the least restrictive intervention based on an individualised assessment of the patient’s medical or behavioural status or condition;
• the safe application and use of all types of restraint or seclusion used in the hospital, including how to recognise and respond to signs of physical and psychological distress (for example, positional asphyxia);
• clinical identification of specific behavioural changes indicating that restraint or seclusion is no longer necessary;
• monitoring the physical and psychological well-being of the restrained or secluded patient — including but not limited to respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1-hour face-to-face evaluation;
• first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification.

Trainers and records

Individuals providing the training must be qualified as evidenced by education, training and experience in techniques used to address patients’ behaviours. The hospital must document in the staff personnel records that training and demonstration of competency were successfully completed — personnel file, not a departmental log.

Practitioner training

Separately, 482.13(e)(11) requires that physician and other licensed practitioner training requirements be specified in hospital policy, and that at minimum those authorised to order restraint or seclusion must have a working knowledge of hospital policy on its use. Ordering practitioners are not exempt from training; their requirement is simply lighter and policy-defined.

Death reporting — 482.13(g)

This is the standard most often missed, because it applies whether or not the restraint episode itself was problematic.

Reportable to CMS by the next business day

With the single exception below, the hospital must report the following to CMS by telephone, facsimile, or electronically as determined by CMS, no later than the close of business on the next business day following knowledge of the patient’s death:

1. each death that occurs while a patient is in restraint or seclusion;
2. each death that occurs within 24 hours after the patient has been removed from restraint or seclusion;
3. each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to the death, regardless of the type of restraint used.

The regulation defines the third trigger further: “‘Reasonable to assume’ in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing, or asphyxiation.”

The soft-wrist-restraint log exception

Where no seclusion has been used and the only restraints used were applied exclusively to the patient’s wrist(s) and composed solely of soft, non-rigid, cloth-like materials, the hospital does not report to CMS but must instead record in an internal log or other system:

• any death that occurs while the patient is in such restraints; and
• any death that occurs within 24 hours after removal from such restraints.

Every element of that exception is a condition. Seclusion anywhere in the episode, any restraint point other than the wrists, or any rigid component removes the episode from the log pathway and back into next-business-day CMS reporting. Note also that the log pathway has no 1-week contributory-death branch — only the in-restraint and 24-hour triggers.

Log entry requirements

For log-pathway deaths, each entry must be made not later than seven days after the date of death, and must document the patient’s name, date of birth, date of death, name of the attending physician or other licensed practitioner responsible for the patient’s care, medical record number, and primary diagnosis(es). The information must be made available in written or electronic form to CMS immediately upon request.

Documenting the report itself

Under 482.13(g)(3), staff must document in the patient’s medical record the date and time the death was either reported to CMS or recorded in the internal log. The report is not complete until the fact of the report is in the chart.

Making the determination: violent or non-violent?

Because so much turns on this classification, it is worth stating what does and does not drive it.

It is driven by the behaviour being managed, not by:

• the unit the patient is on — a behavioural restraint on a medical floor is still a behavioural restraint, and a non-violent restraint on a psychiatric unit is still non-violent;
• the patient’s diagnosis — a psychiatric diagnosis does not make every restraint of that patient a violent-behaviour restraint;
• the device used — soft wrist restraints are used in both categories;
• which order set the ordering practitioner happened to open.

The test is the one the regulation states: is the restraint or seclusion being used for the management of violent or self-destructive behaviour that jeopardises the immediate physical safety of the patient, a staff member, or others? If yes, the age-based order limits, the 1-hour face-to-face evaluation and the trained-RN consultation requirement all apply. If the restraint is being used to protect the physical safety of a non-violent, non-self-destructive patient — the classic case being a confused patient interfering with a medically necessary line or tube — order renewal follows hospital policy and there is no 1-hour evaluation requirement.

Two practical consequences follow. First, a patient’s category can change mid-episode, and the documentation must change with it. Second, hospitals that route everything through the stricter violent-behaviour pathway “to be safe” are not being conservative — they are applying a more restrictive intervention framework than the patient’s condition warrants, which cuts against the least-restrictive requirement at (e)(3), and they generate order-timing deficiencies on episodes that never needed timed orders at all.

Where this standard connects to the rest of hospital compliance

• Care in a safe setting. 482.13(c)(2) — the safe-setting right in the same Condition of Participation — is the hook CMS uses for environmental risk, including ligature risk assessment. Restraint failures and ligature failures are frequently cited together.
• Sentinel events. A death or serious injury associated with restraint use is treated as a reviewable event by accreditors — see sentinel events and what happens next. Accreditor reporting is separate from and additional to the CMS death report under (g).
• Just culture. Restraint episodes that go wrong are a common test case for behaviour classification after an adverse event — see the just culture algorithm.
• Emergency department application. Restraint of a patient presenting to the ED intersects with EMTALA screening and stabilisation obligations; restraint does not suspend the medical screening examination requirement.

Frequently asked questions

What is the 1-hour rule for restraints?

Under 42 CFR 482.13(e)(12), when restraint or seclusion is used to manage violent or self-destructive behaviour jeopardising immediate physical safety, the patient must be seen face-to-face within one hour of initiation by a physician, other licensed practitioner, or a registered nurse trained under 482.13(f), to evaluate the patient’s immediate situation, reaction to the intervention, medical and behavioural condition, and the need to continue or terminate. It does not apply to non-violent restraint.

How long can a restraint order last?

For violent or self-destructive behaviour: 4 hours for adults 18 and older, 2 hours for children and adolescents aged 9 to 17, and 1 hour for children under 9, renewable within those limits up to a total of 24 hours, after which a practitioner must see and assess the patient before a new order. For non-violent restraint, the renewal interval is set by hospital policy. State law may be more restrictive in both cases.

Can a PRN restraint order be written?

No. 42 CFR 482.13(e)(6) states that orders for restraint or seclusion “must never be written as a standing order or on an as needed basis (PRN).”

Can a nurse perform the 1-hour face-to-face evaluation?

Federally, yes — a registered nurse trained in accordance with 482.13(f) may perform it, but must then consult the attending physician or other licensed practitioner responsible for the patient’s care as soon as possible afterwards. States may impose more restrictive requirements, so verify state law before building the nurse pathway into policy.

Is a bed rail a restraint?

It depends on use and effect. The definition turns on whether a device immobilises or reduces the patient’s ability to move freely, and the exclusion covers methods used “to protect the patient from falling out of bed.” A partial rail used for mobility assistance and a full set of rails that prevents a patient from leaving the bed are not the same determination. Document the assessment.

Which restraint deaths must be reported to CMS?

Deaths occurring while in restraint or seclusion, within 24 hours of removal, or within one week where it is reasonable to assume restraint or seclusion contributed directly or indirectly — reported by close of business the next business day. The narrow exception is deaths where no seclusion was used and the only restraints were soft, non-rigid, cloth-like wrist restraints, which are recorded in an internal log within seven days instead.

Does seclusion have the same rules as restraint?

Mostly, but with one categorical difference: seclusion may only be used for the management of violent or self-destructive behaviour. There is no non-violent seclusion pathway. Consequently every compliant seclusion episode carries the age-based order limits and the 1-hour face-to-face evaluation.

Do accreditation standards add requirements?

Yes. Accrediting organisations operating with CMS deeming authority set their own restraint and seclusion standards, and in places these exceed the federal floor — for example on retraining frequency and on documentation detail. This page states the federal requirement only; check your accreditor’s current manual for the additional requirements that apply to your hospital.

Related reading

• Ligature Risk Assessment: CMS Expectations and How to Run One
• Sentinel Event: What It Means, and What Happens Next
• Just Culture Algorithm: How Hospitals Classify Behavior After an Adverse Event
• EMTALA: Screening, Stabilization, and Transfer Rules
• National Patient Safety Goals and the 2026 National Performance Goals change
• Patient Safety & Infection Prevention