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Restraint-Related Citations Could Jeopardize Compliance

By: Donna Gorby, MLD, BSN, RN, Standards Interpretation Specialist

Donna Gorby MLD, BSN, RN, is a standards interpretation specialist for acute care and critical access hospitals. Prior to joining ACHC, she served in various leadership roles including vice president of quality and medical staff services, director of nursing, and regulatory compliance officer. 

Posted: January 2, 2026

Did you know that U.S. hospitals use restraints in nearly 2 million patient episodes every year? While physical restraint is always intended to be a last resort, its use is more common—and more complex—than many organizations realize. Even when used appropriately, restraint-related citations are among the most serious findings during CMS or accreditation surveys. 

ACHC Hospital Accreditation Standards expect safe, clearly defined, and well-understood policies and processes for the use of patient restraints across your entire facility. 

Here are some common compliance gaps related to restraints that could place your organization at risk—and information on how to avoid them. 

 

Is it a restraint?

  • Physical holds: Not all physical contact constitutes restraint. Therapeutic holds, such as supportive or comforting contact with the patient’s cooperation, are not considered restraints. However, if staff hold a patient to prevent harm and the patient cannot freely move, that counts as a restraint.
  • Side rails: If all four bedside rails are raised such that a patient is prevented from exiting the bed freely, this may constitute a restraint.
  • Enclosure beds: Mesh or netting that keeps patients from getting out are considered restraints, except when used for infants or toddlers.
  • Hand mitts: Mittens that immobilize the patient’s hands or severely limit function may be restraints.
  • Chemical restraints: When medications are used primarily to control behavior, not to treat a medical condition, they are considered a restraint. These medications are not the same as PRN medications, which are ordered for therapeutic use and involve patient participation. Chemical restraints are given without patient collaboration when other methods have failed. PRN medications are requested or accepted by the patient for therapeutic benefit. Chemical restraints may go unrecognized; be alert for these situations and intervene as needed.
A risky rationale: Restraint for sedation or fall prevention

Restraint is not appropriate for sedated patients unless unsafe behavior is present. CMS clearly states that restraints of any kind should only be implemented while unsafe conditions exist and discontinued at the earliest possible time. Patients who are sedated and are not posing a threat should not be restrained. Review your organization’s processes and make sure that nonviolent restraints are not routinely applied to sedated patients as part of a protocol.

Similarly, restraining a patient to prevent falls is not only noncompliant—it’s dangerous. Studies show that patients who are restrained fall more frequently and are more likely to die than patients without restraint.

 

 

Are all relevant staff properly trained?

Trainers must have documented education and experience in restraint use, as well as experience in techniques used to address patients’ behaviors.

  • Non-nursing staff: If your security, respiratory, behavioral health, or other non-nursing staff assist in the application or monitoring of restrained patients, they must receive the required training per CMS requirements.
  • Physician training: At a minimum, your organization should have a process that outlines which practitioners can order restraints and document evidence that these providers are trained in your hospital’s restraint policy.

 

Documentation details

Violent restraint orders must be renewed according to ACHC Standards. Nonviolent restraints may be renewed per your organization’s policy. This flexibility does not mean that a renewal order isn’t needed. Safeguard your patients by requiring providers to reassess, renew, and reorder nonviolent restraint at frequencies that ensure safety, dignity, and independence.

Hospitals must report to CMS any death that occurs during restraint or seclusion, within 24 hours of restraint removal or within one week of removal if the restraint or seclusion may have contributed to the death. Exceptions apply when only soft, nonrigid wrist restraints were used without seclusion. In such cases, hospitals must maintain an internal log of these deaths and be prepared to present it upon request from CMS or ACHC.

Don’t forget to incorporate restraint audits that identify opportunities for improvement into your hospital-wide QAPI Program.

 

Final takeaway

Making sure your restraint practices are safe and compliant isn’t just about avoiding citations; it’s about doing what’s right for your patients. By clarifying gray areas, keeping your team well-trained, and staying up to date with documentation, you help create a safer environment for everyone. A few simple changes can go a long way in protecting patients, supporting your staff, and keeping your hospital survey ready.

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