Violence in Healthcare and the Use of Handcuffs

In May of 2018, OSHA cited Premier Behavioral Health Solutions of Florida and UHS of Delaware, for failing to protect employees from violence in the workplace.  OSHA was responding to a complaint that employees were not adequately protected from violent mental health patients. OSHA cited the two organizations who jointly operate the Suncoast Behavioral Health Center for failing to institute controls to prevent verbal and physical assaults by patients and from using objects as weapons.  Proposed penalties total $71,137.[19]

These are only examples of the many citations that OSHA has issued over the past several years making clear their position that creating an environment for healthcare employees that is safe from patient violence is paramount and steep fines will be imposed against organizations who do not.

Dueling Mandates

From the regulatory overview, the following is clear:

  • Private security officers working in the healthcare setting are legally permitted to use handcuffs as a means of detaining people in a variety of situations
  • CMS strongly oppose the use of handcuffs in any situation where a patient is involved
  • OSHA wants healthcare employees to be protected from workplace violence, including violent patients, and will fine facilities for failing to protect them

Herein lies the problem.  These two federal agencies are in direct conflict with who is the primary person to protect…is it patients or staff?  Adequately protecting both, while following the guidelines, is challenging.

Consider Lehigh Valley Hospital in Pennsylvania, which was cited by CMS in 2010 for using CEWs in situations involving patients.[20]  These weapons are specifically mentioned in the same CMS guideline that addresses handcuffs and can be used as part of a law enforcement level action only.  The four situations in which stun guns were used at Lehigh were as follows:

  • An agitated patient in the Emergency Department received multiple doses of psychiatric medication during a two hour period and was still agitated. Security staff was called and the patient “came at” security, at which point a CEW was used.
  • A patient became agitated and began yelling at staff. The patient was using an intravenous pole as a weapon and barricaded himself in the restroom.  Security talked to the patient, but he continued to escalate and ultimately a CEW was used.  Police were called and took a report.
  • An ED patient ran out of an examination room, slamming the door, hitting the wall and yelling. Medical staff tried to calm the person and eventually involved security.  The patient attempted to punch a security officer who then took the patient to the ground.  The patient continued to fight with two officers and one used a CEW to subdue him.
  • An upset patient left the ED. Security staff called police and pursued the person for fear he would harm himself or others.  The patient pushed a security officer, striking the officer with his fist and grabbing for the officer’s belt containing pepper spray and a CEW.  Another officer warned the patient three times and then discharged a CEW.

Lehigh Valley officials argued that each of these situations constituted law enforcement level action because the patients’ actions had risen to the criminal level and the actions taken were not part of the normal course of patient care.  The citations stood, however, which jeopardized Lehigh’s Medicare and Medicaid status.[21]  Lehigh elected to take CEWs away from security officers which raised the question again of employee safety.  Consider each of the aforementioned extreme situations had the security officers not had access to devices to help control the individuals who were acting out.  Would they have been able to prevent injury to staff?



Prisoner Patients

Prisoner patients, patients who are in the custody of law enforcement while needing medical treatment, are the easiest situations for which to discuss the use of handcuffs because they are the most straightforward.  The custodial officer who is with the patient is responsible for the use of handcuffs while treatment occurs.  That does not, however, absolve the medical care facility of a responsibility to protect the patient while treatment is being rendered.  For example, if handcuffs are too tight or are impeding medical treatment, the healthcare worker must assess the safety of continued use of restraint. Security officers should work hand in hand with custodial officers to ensure the process of treating a prisoner patient, while maintaining a safe environment, goes smoothly.

Some best practices related to the management of prisoner patients – particularly those who will be remaining in handcuffs throughout their treatment – include:

  • Conduct a meeting between local law enforcement, corrections officers, hospital security and medical care staff prior to the prisoner patient coming to the facility to review roles and responsibilities of each person in effecting safe care for the prisoner patient and maintaining safety of the environment
  • When law enforcement arrives on site with a prisoner patient, a hospital security officer should meet and escort them to the designated area of treatment and review with them the meanings of codes and discuss the actions the law enforcement officer will take in each situation.
  • Security officers should maintain close contact with the custodial officer but should not at any time take responsibility for the patient. Hospital security officers are responsible for the general safety and security of the hospital, staff, visitors and patients, but prisoners are the responsibility of the custodial officer.
  • If removal of handcuffs is needed to effect treatment, it should be handled by the custodial officer. If the custodial officer is working alone, it may be helpful for a security officer to assist in monitoring the prisoner patient while he is not handcuffed as this presents the highest risk to the facility.[22]

A sample policy regarding prisoner patients from Aurora Health is available online.[23]

Medical Patients

There are many medical conditions that can cause aggressive behavior.  Recognizing these signs early allows for more proactive management of the patient and a decreased likelihood of a violent incident occurring during which the patient or others may be hurt.[24]  Security officers are part of the care team and, as they are often on standby with patients in the emergency department while their potential for violence is assessed, they can play a key role in recognizing opportunities for intervention.  Medical causes of aggression include head injury, mental illness, low blood sugar, swelling in the brain from infection, the post ictal state that follows a seizure and a stroke or brain bleed, among others.  Dementia, schizophrenia, anxiety, acute stress and suicidal ideation have also been found to be predictors of violence against healthcare workers.[25]

[19] Occupational Safety and Health Administration.  “U.S. Department of Labor Cites Florida Health Facility for Exposing Employees to Workplace Violence.” OSHA News Release – Region 4, May 2, 2018. Retrieved September 21, 2018 from

[20] Darragh, Tim.  “Lehigh Valley Hospital stunned patients.”  The Morning Call, December 10, 2010,

[21] Greene, Jan. “Patient Safety Versus Workplace Safety: Stun gun debate illustrates dueling federal mandates.” Annals of Emergency Medicine, vol. 57, no. 4, 2011, pp. 20A–23A.  DOI:

[22] Gorman, Erin.  “Lessons Learned & Best Practices for Managing Forensic Patients in Healthcare Facilities.”  IAHSS Foundation Evidence Based Research Series.  April 20, 2016.  IAHSS-F RS-16-02

[23] Aurora Health.  “Prisoner Patients (Care of Patients under Legal or Correction Restrictions.” Policy No – Clin 484, June 2015.  Retrieved June 22, 2018 from rehab/art/prisoner-patient.pdf

[24] Guthrie, Kane.  “Behavioural Emergencies.”  Life in the Fast Lane.  October 9, 2017.

[25] d’Ettorre, Gabriele et. al.  “Preventing and managing workplace violence against healthcare workers in Emergency Departments.” Acta Biomed for Health Professions, vol. 89, s. 4, 2018, pp. 28-36.  DOI: 10.23750/abm.v89i4-S.7113