6.3 Restraints, Restraint Alternatives, and OBRA Requirements
Key Takeaways
- OBRA guarantees residents' right to be free from restraints used for discipline or staff convenience
- Restraints require a physician's order for a specific medical reason, using the least restrictive device
- Restrained residents must be monitored every 30 minutes and released every 2 hours
- Restraints can cause strangulation, skin breakdown, falls, depression, and increased agitation
- Alternatives include bed/chair alarms, low beds, floor mats, toileting schedules, and activity programs
- Two-finger rule: always be able to fit two fingers between the restraint and the resident's skin
Last updated: March 2026
Restraints, Restraint Alternatives, and OBRA Requirements
The use of restraints is one of the most regulated areas in long-term care. OBRA regulations and Illinois law severely restrict the use of both physical and chemical restraints. A resident has the right to be free from any restraint that is not medically necessary and ordered by a physician. This is a heavily tested topic on the INACE.
What Are Restraints?
| Type | Definition | Examples |
|---|---|---|
| Physical Restraint | Any device, material, or equipment that restricts a person's freedom of movement | Vest restraints, wrist/ankle restraints, lap belts, bed rails (when used to prevent getting out of bed), wheelchair lap trays that cannot be removed by the resident |
| Chemical Restraint | Any drug used for discipline or convenience rather than treatment | Sedatives, antipsychotics, or anti-anxiety medications used to control behavior rather than treat a diagnosed condition |
OBRA Restraint Regulations
| Regulation | Details |
|---|---|
| Residents' right | Freedom from restraints used for discipline or staff convenience |
| Medical necessity | Restraints may ONLY be used when medically necessary for treatment |
| Physician order | A physician must order the restraint with a specific medical reason |
| Least restrictive | The least restrictive device must be used for the shortest time |
| Regular reassessment | Must be regularly reassessed for continued need |
| Release schedule | Restraints must be released at regular intervals (typically every 2 hours) |
| Monitoring | Resident must be monitored at least every 30 minutes when restrained |
| Documentation | All restraint use must be documented including reason, type, and monitoring |
Dangers of Restraint Use
| Danger | Explanation |
|---|---|
| Strangulation | Leading cause of restraint-related deaths |
| Skin breakdown | Pressure from restraint devices causes skin injury |
| Circulation impairment | Tight restraints restrict blood flow |
| Nerve damage | Pressure on nerves from wrist/ankle restraints |
| Increased agitation | Restraints often increase rather than decrease agitation |
| Falls | Residents attempt to climb over restraints, increasing fall risk |
| Contractures | Immobility leads to muscle shortening and joint stiffness |
| Depression | Loss of freedom and autonomy cause emotional harm |
| Aspiration | Vest restraints can shift and compress the chest |
Restraint Alternatives
CNA-implemented alternatives that reduce the need for restraints:
| Alternative | Application |
|---|---|
| Toileting schedules | Reduce restlessness caused by urgency |
| Activity programs | Meaningful engagement reduces wandering and agitation |
| Bed alarm/chair alarm | Alerts staff when resident attempts to get up |
| Low bed | Reduces injury risk if resident falls out of bed |
| Floor mat | Cushion beside the bed to reduce injury from falls |
| Wedge cushions | Helps maintain positioning without restricting movement |
| One-on-one attention | Sitting with an agitated resident provides comfort |
| Music therapy | Calming music reduces anxiety and agitation |
| Adequate lighting | Reduces confusion and sundowning behaviors |
| Pain management | Report signs of pain — untreated pain causes agitation |
| Diversional activities | Puzzles, books, crafts, conversation |
| Reclining wheelchair | Provides comfort without restraining |
CNA Responsibilities When Restraints Are Ordered
If a physician has ordered a restraint, your responsibilities include:
- Check the care plan for the specific type, schedule, and release requirements
- Apply correctly — Never apply restraints you have not been trained on
- Check circulation — Ensure you can fit two fingers between the restraint and the resident's skin
- Release every 2 hours — Provide range of motion, toileting, fluids, repositioning
- Monitor every 30 minutes — Check for breathing, circulation, skin integrity, comfort
- Document — Record all checks, releases, and observations
- Report concerns — Any signs of distress, skin breakdown, or circulation problems to the nurse immediately
Test Your Knowledge
Under OBRA, restraints may only be used when:
A
B
C
D
Test Your Knowledge
How often must a CNA check on a restrained resident?
A
B
C
D
Test Your Knowledge
Which of the following is a restraint ALTERNATIVE that a CNA can implement?
A
B
C
D