Rights and restraints: The need for good restraint and seclusion policies

In 2017, a Missouri hospital found out the hard way that when not addressed quickly, restraint and seclusion deficiencies can spiral out of control. Twice in one year, CMS ruled that Mercy Hospital Springfield was putting patients in immediate jeopardy after inspectors found problems with the way the facility was handling cases of possible abuse and neglect.

Some of the incidents in question involved the use of restraint and seclusion, such as when a nurse pinned a violent patient to the floor and didn't report it. At least 12 hospital staffers were fired as a result, with a hospital spokesperson saying their behavior in “highly tense situations” was deemed inadequate.

This story should be a reminder to revisit when and how often your staff are trained in the relevant policies and procedures, and consider adding or increasing de-escalation training to help ensure that patient rights are respected.

Restraint and seclusion
CMS defines a restraint as "any manual method, physical or mechanical device, material, or equipment that immobilizes 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 behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition."

Seclusion, meanwhile, is defined as involuntarily confining a patient alone in a room or area and preventing him or her from leaving.

The misuse of restraints has led to death by asphyxiation, as well as complications such as nerve injuries, incontinence, pneumonia, and pressure ulcers. But despite the dangers, CMS says it’s documented over 1,400 related deficiencies between 2011 and 2015.

While there are times when restraints and seclusion are needed, such as with patients under arrest, those circumstances are very limited. CMS says restraints and seclusion should only be used to ensure the immediate physical safety of the patient, staff members, or others, and should be discontinued as soon as possible. And they should only be used when other options are ineffective.

Know how to de-escalate
The first investigation into Mercy Hospital began in January 2017, when surveyors found significant patient rights violations related to incidents in the hospital’s Behavioral Health Unit (BHU), according to an inspection summary report published on the Association of Health Care Journalists’ HospitalInspections.org site.

One incident involved a patient diagnosed with schizoaffective disorder admitted just three days before the inspection, according to the January inspection report. The patient was admitted to the BHU shortly before 5 a.m. and quickly was in a confrontation with a registered nurse. As is standard practice, the public report did not include names of staff or patients, to protect privacy.

The patient screamed and spat on the nurse’s chest, according to the report, which cited an audiovisual recording of the encounter. “Don’t ever spit on me again,” the nurse said, moving forward toward the patient.

When the patient raised his right arm, the nurse pushed it back down. The patient used his other hand to punch the nurse in the face, then the nurse “charged forward and struck the patient in the face/neck area,” pushing him up against a wall as the patient continued to strike the nurse’s head and neck. The nurse then “slammed the patient to the floor,” the report states.

“That was a major mistake. I will press charges, guaranteed,” the nurse said.

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