Restraint-Free Environment Assessment Checklist
Assessment of restraint-free alternatives and least restrictive interventions to maintain patient safety while preserving dignity.
- Industry: Healthcare
- Frequency: Per patient/Ongoing
- Estimated Time: 15-20 minutes
- Role: Nurse/Care Team
- Total Items: 31
- Compliance: CMS CoP 42 CFR 482.13, Joint Commission PC.03.05, State Regulations
Behavior Assessment
Current behaviors
- Behavior requiring intervention identified?
- Root cause of behavior explored?
- Medical causes ruled out?
Alternatives Attempted
Non-restraint interventions
- Verbal de-escalation attempted?
- Reorientation attempted?
- Environmental modifications made?
- Family/sitter involvement considered?
- Pain and comfort addressed?
- Diversional activities offered?
Safety Devices (Non-Restraint)
Alternative safety measures
- Bed/chair alarm in place?
- Low bed position?
- Floor mat in place?
- Increased observation?
Pre-Assessment Information
Initial assessment documentation and patient/facility identification
- Assessor Name / Credentials
- Assessment Date
- Department / Unit
- Assessment Type (Routine/Annual/Complaint)
- Previous assessment findings reviewed?
Infection Prevention & Control
Verify infection control practices per CDC and Joint Commission standards
- Hand hygiene compliance observed?
- Appropriate PPE available and properly used?
- Isolation precautions properly implemented?
- Sharps containers available and not overfilled?
- High-touch surfaces properly disinfected?
Patient Safety & Identification
Verify patient safety protocols and identification procedures
- Two patient identifiers used before procedures?
- Fall risk assessment completed?
- Call light within patient reach?
- Bed in lowest position with brakes locked?
Medication Safety & Management
Verify medication handling and administration practices
- Medications stored securely and at proper temperature?
- Controlled substances properly secured and counted?
- No expired medications in stock?
- High-alert medications properly labeled?
Related Healthcare Checklists
- Pediatric Early Warning Score (PEWS) Checklist
- Modified Early Warning Score (MEWS) Assessment Checklist
- Clinical Alarm Management Checklist
- Patient Identification Verification Procedure Checklist
- Emergency Department Triage Assessment Checklist
- Critical Lab Value Notification Checklist
- Care Coordination Transition Checklist
- PCA Monitoring Checklist
Related Patient Safety Checklists
- Patient Fall Prevention Assessment Checklist - FREE Download
- Surgical Site Marking & Time-Out Checklist - FREE Download
- Patient Restraint Assessment & Monitoring Checklist - FREE Download
- Healthcare Infection Control Audit Checklist - FREE Download
- Patient Discharge Planning Checklist - FREE Download
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- Patient Identification Audit - FREE Download
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Why Use This Restraint?
This restraint helps healthcare teams maintain compliance and operational excellence. Designed for nurse/care team professionals, this checklist covers 31 critical inspection points across 7 sections. Recommended frequency: per patient/ongoing.
Ensures compliance with CMS CoP 42 CFR 482.13, Joint Commission PC.03.05, State Regulations. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the Restraint cover?
This checklist covers 31 inspection items across 7 sections: Behavior Assessment, Alternatives Attempted, Safety Devices (Non-Restraint), Pre-Assessment Information, Infection Prevention & Control, Patient Safety & Identification, Medication Safety & Management. It is designed for healthcare operations and compliance.
How often should this checklist be completed?
This checklist should be completed per patient/ongoing. Each completion takes approximately 15-20 minutes.
Who should use this Restraint?
This checklist is designed for Nurse/Care Team professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.
Can I download this checklist as a PDF?
Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.