DHDTC DAL 17-13 - Security Guards and Restraints

November 2, 2017

DHDTC DAL 17-13: Security Guards and Restraints

Dear Chief Executive Officer:

This letter is written to provide you information about Immediate Jeopardy (IJ) determinations related to the application of restraints by security guards and other personnel. The purpose of sharing this information is to assist your facility in recognizing the basis for IJ determinations in this area, evaluating your policies, procedures, and practices, and ensuring that your facility is in compliance with regulatory requirements. Compliant practices minimize the potential for patient harm.

Of the seven IJ determinations related to restraints that were issued by the Department in calendar year 2016, five were related to the lack of training in CPR and first aid for security personnel involved in the application of restraints and two were related to the use of handcuffs as a restraint. In 2017 to date only one IJ was issued related to improper use of restraints. It is strongly recommended that hospitals review their policies and procedures related to the application of restraints, focusing specifically on the personnel, including security guards, who apply restraints or who could be asked to apply or assist in the application of restraints, and the training that they must receive. In addition, hospitals should review and train staff on appropriate methods of restraint; as a reminder, Appendix A of the CMS State Operations Manual states that the use of metal handcuffs to restrain patients is not allowed, unless the patient is in the custody of police and/or correctional officers.

Federal regulations at 42 CFR 482.13 define accepted standards and requirements related to restraint and seclusion (42 CFR 482.13 (e)), staff training requirements (42 CFR 482.13 (f)), and death reporting requirements (42 CFR 482.13 (g)). Please review the regulations and associated interpretive guidelines to inform your review of policies, procedures, and practices. They can be found at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Hospitals.html. Please keep the following in mind:

  • Patients have the right to be free from restraints of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint 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. (42 CFR 482.13 (e)).
  • Hospitals must maintain policies and procedures that clearly identify staff who are authorized to use restraints, including physical and chemical restraints. Policies and procedures must describe the appropriate use of physical and chemical restraints, as well as, the use of de-escalation techniques and alternatives to restraints, timely release of restraints and timely reassessment (42 CFR § 482.13).
  • Hospitals must ensure that all staff are aware of which staff are authorized to apply restraints and of the facility procedures for requesting the application or assistance with the application of appropriate restraints.
  • Hospitals must ensure that all staff who are authorized to apply restraints or care for patients in restraints, including security personnel, are trained in cardio-pulmonary resuscitation, first aid, and the appropriate use of restraints (including physical holds), and that they are trained and understand when it is appropriate to apply a restraint and what restraint is appropriate to use as outlined in the hospital policies and procedures. Often, clinical personnel are trained as required but security staff who apply restraints are not (42 CFR §482.13(f)(2)(vii) interpretive guidelines).
  • Hospitals must ensure that security staff are specifically authorized and trained to use restraints and are not utilizing law enforcement devices such as handcuffs, chains, manacles, leg irons, etc. to restrain patients (42 CFR §482.13(e) interpretive guidelines).
  • Staff who are authorized to apply restraints must receive appropriate training, and demonstrate competency, before applying any restraint, as part of orientation, and periodically thereafter at a frequency determined by the hospital (42 CFR 482.13 (f) (1)).
  • Hospitals must document in personnel records that training and demonstration of competency were successfully completed. (42 CFR 482.13 (f) (4)).

Thank you for your attention to this important patient safety matter. Continued compliance with standards and regulatory requirements will reduce the potential for harm to patients, staff, or others, and minimize the likelihood of an Immediate Jeopardy citation. Please contact the Division of Hospitals and Diagnostic & Treatment Centers at 518-402-1004 with any questions about the content of this letter.


Ruth Leslie, Director
Division of Hospitals and Diagnostic & Treatment Centers