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State of California—Health and Human Services Agency
California Department of Public Health

AFL 12-36
September 25, 2012

Skilled Nursing Facilities

Physical Restraint Reduction in Skilled Nursing Facilities

The Centers for Medicare and Medicaid Services (CMS) and the California Department of Public Health (CDPH) are committed to reducing the use of unnecessary physical restraints in skilled nursing facilities. Currently, California ranks 48th in the nation for the use of unnecessary physical restraints in skilled nursing homes. The nationwide rate for physical restraints is 2.2%; however, California's rate is 3.8%. In addition, a subgroup of CMS identified skilled nursing homes with the highest physical restraint utilization in California have a combined rate of 11%.

The CDPH's Center for Health Care Quality Division and Health Services Advisory Group, California's Quality Improvement Organization (QIO), strongly support CMS' goal to reduce physical restraint use and are working collaboratively to eliminate unnecessary restraints in California.

This letter identifies regulations in place concerning physical restraints and other references as resources to enable facilities to improve their physical restraint reduction programs in their facilities.

One of the barriers to reducing the use of unnecessary physical restraints is that staff may be reluctant to begin physical restraint reduction programs for fear residents will fall without physical restraints. However, physical restraints do not eliminate the risk of falling. On the contrary, physical restraints have been found to increase the risk for a number of adverse outcomes. After 10 years of aggressive studies, researchers have concluded that there is no evidence to support physical restraint use for fall prevention. On the contrary, physical restraints have been found to increase the incidence of falls or head trauma due to falls and other accidents.

Many providers believe that physical restraints are generally necessary to prevent residents from harm. However, the use of physical restraints can cause harm; including: strangulation, loss of muscle tone, decreased bone density (with greater susceptibility for fracture, pressure ulcers, or decreased mobility), depression, agitation, loss of dignity, incontinence, constipation and death. Therefore, education about the dangers caused by physical restraints, and the alternatives that may be used, is important. In particular, residents, providers and family members need to be informed of the hazards of physical restraints.


  • The CMS State Operations Manual (SOM) provides guidance for CDPH surveyors on how to evaluate whether a skilled nursing facility is following the regulations regarding physical restraints. The SOM may be found at the CMS website:
    The sections of the SOM that deal with physical restraints are primarily Section 483.13(a) on restraints and secondarily Section 483.20(k)(2)(ii) and Section 483.10(b)(4), the sections that deal with a resident's right to participate in care planning and the right to refuse treatment. Another regulation that may be helpful is Section 483.25(h) on accidents.
  • In 2007, CMS issued Survey and Certification Letter 07-22 (S&C 07-22), which provided clarification to the following definitions related to physical restraints:
    "Freedom of Movement" means any change in place or position for the body or any part of the body that the person is physically able to control. "Remove Easily" means that the manual method, device, material, or equipment can be removed intentionally by the resident in the same manner as it was applied by the staff.
    "Medical Symptom" means an indication or characteristic of a physical or psychological condition. Before a physical restraint is used, the facility must have a specific medical symptom that cannot be addressed by another less restrictive intervention. The physical restraint must be required to treat the medical symptom, protect the resident's safety, and help the resident attain or maintain his or her highest level of physical or psychological well-being. There must be a link between the physical restraint use and how it benefits the resident by addressing the medical symptom. Medical symptoms that warrant the use of physical restraints must be documented in the medical record and have a physician's order reflecting the presence of the medical symptom.
    The S&C Letter 07-22 includes other clarifications that will be helpful to your skilled nursing home as you move forward with restraint reduction. A full copy of the S&C Letter 07-22 may be found at the CMS website:
  • Additional resources that may assist in reducing restraints may be found on the Advancing Excellence in America's Nursing Homes website:( under implementation guides.

CDPH believes that every skilled nursing facility must protect the rights, as well as the safety, of each resident. Nationwide providers have made great strides in reducing daily physical restraint use in their nursing homes. If you have not already, both CDPH and the QIO encourage the development of a physical restraint reduction program in your skilled nursing home to bring your rates in line with the nationwide average of 2.2% and to ensure residents become free of unnecessary physical restraints. We believe that freedom from physical restraints is one very important way to allow residents to attain and maintain the highest practicable physical, mental, and psychosocial well-being.

If you have any questions regarding physical restraint reduction, please contact your local Licensing and Certification District Office.



Original signed by Debby Rogers

Debby Rogers, RN, MS, FAEN
Deputy Director
Center for Health Care Quality

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