Some examples of the acceptable use of handcuffs by private security officers in the healthcare setting, using the citizen’s arrest guidelines, might include detaining:

  • A shoplifter
  • Visitors for physically fighting
  • A family member for causing a disturbance on the property and refusing to leave
  • A person for distributing illegal substances
  • A person for making threats with a weapon

If the person who commits a crime is also a patient at the facility, the use of handcuffs becomes much more complicated.  Patients will be discussed in detail in the following section.

CMS

Using handcuffs to restrain patients, is far more complex and generally ill advised.  The following is an excerpt from the CMS Interpretive Guideline §482.13(e):

“CMS does not consider the use of weapons in the application of restraint or seclusion as a safe, appropriate health care intervention. For the purposes of this regulation, the term weapon includes, but is not limited to, pepper spray, mace, nightsticks, tasers, cattle prods, stun guns, and pistols. Security staff may carry weapons as allowed by hospital policy, and State and Federal law. However, the use of weapons by security staff is considered a law enforcement action, not a health care intervention. CMS does not support the use of weapons by any hospital staff as a means of subduing a patient in order to place that patient in restraint or seclusion. If a weapon is used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to protect people or hospital property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement. The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are not governed by this rule. The use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients.”[14]

In short, handcuffs are not permissible for use in any way if the goal of the interaction is to restrain the person for medical treatment. The only time it is allowable to use handcuffs to restrain a patient is if he commits a crime for which law enforcement will be notified with the expectation that the patient will be charged with a crime.  For example, if a patient kicks a caregiver during assessment or treatment, he has committed the crime of battery; however, the patient may have a medical condition such as a head injury that makes him unaware of, or unable to control, his actions.  A crime has been committed, but without intent, it is unlikely the hospital administration or local law enforcement would view the situation as criminal.  The goal is to medically restrain the patient in a way that is safe for staff and the patient so that treatment can continue.  In this example, the use of handcuffs is not appropriate under CMS guidelines.

Consider a different example where a patient is being seen in the emergency department for pain and wants to be prescribed a narcotic medication.  When not given the narcotic he is seeking, the patient grabs hold of the caregiver and pushes her against a wall screaming that he wants his narcotic. This is a similar situation of assault and battery.  However, in this circumstance, the patient is willfully taking criminal action.  The use of handcuffs may be appropriate here as staff is no longer attempting to treat the person but rather safely control the person until law enforcement arrives to take custody.  Notice the use of the word “may.”  We will see later that even in situations that appear to meet the criteria for law enforcement level action under the CMS guideline, it is not necessarily interpreted that way by CMS.

With regard to application of restraints, CMS demands patients are managed with the minimum necessary force to control.  Even for medical restraint application, CMS has strict guidelines and prefers patients are managed with proactive de-escalation techniques to limit the use of any kind of restraint when at all possible.

OSHA

OSHA does not have specific regulations for workplace violence nor do they have a specific stance on the use of handcuffs.  They simply expect employers to take the necessary actions to create a safe environment for employees.  Under the General Duty Clause Section 5(a)(1) of the Occupational Safety and Health Act of 1970, employers are required to provide a place of employment that is “free from recognized hazards that are causing or are likely to cause death or serious harm.”[15]  OSHA’s purpose is to protect employees in the work place and the agency does not care why a healthcare worker is assaulted.  Over the past 10 years as work place violence in healthcare has accelerated beyond that of many other industries, OSHA has taken a harder stance and cited several large healthcare facilities for failure to protect employees from work place violence.

In July of 2013, OSHA cited Armstrong Center for Medicine and Health in Kittanning, Pennsylvania with two violations following a complaint alleging that workers were being assaulted by patients in the hospital’s behavioral health unit.  The serious citations were for hazards associated with the employer’s failure to implement programs and procedures to protect workers from injuries resulting from assaults by patients with proposed penalties of $8,000.[16]

In July of 2015, Brookdale University Hospital and Medical Center in Brooklyn, New York reached a settlement with OSHA stemming from a 2014 visit after a nurse was assaulted.  OSHA found approximately 40 incidents of workplace violence reported over a three month period including head, eye, face and groin injuries, intimidation and threats during routine interactions with patients and visitors.[17]   The most serious incident was the assault of a nurse, who sustained brain injuries when she was attacked while working.  Proposed fines of $78,000 were reduced to $15,000 in the final settlement when the medical center agreed to implement and maintain a comprehensive program to safeguard its employees better against assaults and other on-the-job violence.  The agreement includes specific engineering and administrative controls such as improved employee training and communication, engagement of outside consultants and more holistic violence prevention efforts.[18]

[14] Centers for Medicare & Medicaid Services. CMS state operations manual, appendix A. Regulations and interpretive guidelines for hospitals. Section 482.13(e).  Retrieved August 2, 2018 from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

[15] Occupational Safety and Health Administration. “Preventing Workplace Violence in Healthcare.” Retrieved September 9, 2018 from https://www.osha.gov/dsg/hospitals/workplace_violence.html

[16] Occupational Safety and Health Administration.  “Kittanning, Pa., hospital fined by the US Labor Department’s OSHA for failing to protect workers from patient assaults.” OSHA News Release – Region 3, July 15, 2013. Retrieved September 21, 2018 from https://www.osha.gov/news/newsreleases/region3/07152013

[17] Occupational Safety and Health Administration.  “Brooklyn medical facility cited by US Department of Labor’s OSHA for inadequate workplace violence safeguards Brookdale University Hospital and Medical Center inspected after worker complaints.” OSHA News Release – Region 2, August 11, 2014. Retrieved September 21, 2018 from https://www.osha.gov/news/newsreleases/region2/08112014

[18] Occupational Safety and Health Administration.  “More employee protections against workplace violence, thanks to changes at Brookdale University Hospital and Medical Center.” OSHA News Release – Region 2, July 6, 2015. Retrieved September 21, 2018 from https://www.osha.gov/news/newsreleases/region2/07062015