Painful Use of Restraints

From the Desk of Kathi Ann Stringer

February 24, 2003

Theresa Galvez
Department of Patients’ Rights
P.O. Box 7549
Riverside, California 92513
(909) 358-4600


Reference: Notice of Painful Use of Restraints

Dear Theresa,

Thank you for contacting me regarding the chronic and exceptionally painful application of five-point-restraints used against me on February 19th.   The event took place at the Oasis Treatment Center.  Since our conversation I have spoken with Becky from your Quality Department per your instructions.  She examined the hospital’s policy concerning restraints and discovered that the only requirement as to body arrangement was the ‘prone position.’ 

I have researched several of the available California regulations for public viewing and was disappointed that I could not find any explicit instructions concerning placement of the body extremities during the use of restraint to prevent chronic and acute pain.  However, it did appear there are other preventive measures in place to compensate for this wide latitude and prevent acute and distressful unnecessary pain.  Title 9 provides safeguards to prevent this type of chronic pain utilizing these instruments: (1) assessments at least every 15 minutes, (2) face-to-face interaction to assess distress, (3) range of motion exercise for at least 10 minutes every two hours, (4) reposition client when appropriate, (5) release client when conditions met.  In addition, Title 9 provides accountability safeguards. Treatment staff shall document and report the following when a patient is in restraints: (a) Care to client while in restraints, (b) 15 minute assessments, (c) methods used to determine if a client was not in distress. And finally, the least restrictive method – i.e. the secondary restraints was cinched up to the last notch and unnecessarily prevented limited movement.

This material was not developed and researched ‘to get someone into trouble’ but to serve, as a testament to the severe lack of insight to control what appeared to be punitive retaliatory conduct toward me from staff.  I am dismayed that my cries and screams went unanswered for over forty minutes.  This strikes me as a substantial lack of human compassion in a business that requires knowledge of trauma and skillful use of treatment modalities.

I am concerned that I when I was screaming in distress staff did not seem interested in providing relief.  I would also venture that this incident is not isolated to me but widespread.  It is not unreasonable to reach this conjecture since often the Mental Health Workers (MHW) are hired without training.  Once hired, the MHW ‘training’ amounts to a casual ‘walk through’ of policy.  In addition, in-service training has only a limited effect that is directly linked to staff turnover, fading memories and lack of coaching. 

Another concern is that staff has the attitude of ‘staying on the same page and not dropping the ball’ which has positive and negative components.  The negative component is the distorted assumption that a patient is ‘splitting staff’ when crying out for intervention.  It is reasonable to conclude that staff in lower positions is not going to risk job loss and confront middle management that may create a rift and unpleasant consequences…i.e. job loss, hours cutback, pass over for promotions and etc.  Note the following example:

An MHW reports non-compliance directly to the Director of Nursing (DOM).  The Director of Nursing reprimands the charge nurse.  The charge nurse may be vindictive and set into motion a distorted smear campaign to destroy the MHW.  The example is noted within the team to stave off further non-compliance reporting.

These problems are not unique to Oasis Treatment Center.  They are intrinsic within the current mental health system due to inadequate training and accountability flow errors.

I have outlined below the problems surrounding this event.


1.       Restraints were applied to cause chronic pain.

2.       Staff appeared satisfied I was having problems, as if the tables were turned. I did not feel safe.  I felt punished.  There was no feeling of safety in chronic pain.

3.       The Charge Nurse (Norma) did not investigate the situation for assessment with her RN training but instead relied on a MHW (Matt) to make that assessment for her.

4.       The secondary arm restraints (longer ones) were cinched up tight as possible.  There were no holes exposed on one side of the buckle.

Corrective Action Requested:

1.       Frequent in-service training addressing the appropriate use of restraints in the least painful position.

2.       Frequent in-service training addressing the current statues and regulations provided by law.

3.       Develop a study packet and quiz for newly trained staff, and retest all staff periodically (written and oral) to insure quality compliance, and track score results though the quality department.

4.       Examine all current policies in place concerning use of restraints and request necessary revisions to prevent staff non-compliance and patient emotional and physical injury.

5.       Develop a concrete plan with measurable objectives.

Corrective Action taken in the interim: 

  1. I was impressed with Geri Thompson’s (DON) swift measures in an attempt to arrest and prevent continued non-compliance concerning the painful application of restraints.  This is surly a demonstration of her nursing dedication and empathy toward the patients. 
  2. It appeared from what I have witnessed Geri conducted a meeting to discuss and examine the least painful application of restraints.
  3. It appeared from what I have heard that Geri ordered in-service training to address this problem.

Additional concern regarding interim Corrective Action:  The above Corrective Action did not appear to address revision of documented policy, testing, frequent training, accountability to prevent staff non-compliance and patient emotional and physical injury, patient assessment by trained RN, and other measurable objectives.

To help facilitate this process I have included,

a)    current regulation,

b)   my statement of events while I was in restraints that were written hours after the offence,

c)   an account of the first time I was in restraints and how panic played a terrifying role in the aspect of abandonment. 

You have my complete cooperation to help resolve this problem within the mental health system.  Once you have investigated and negotiated a framework for Corrective Action, please advance the results to my desk for consideration toward possible legislation if appropriate.

Theresa, thank you for your respect, empathy and desire to help with a warm personal regard.  Your diligence and resolve to uphold the law to protect patients that are unable to protect themselves continues to impress me.  No matter the outcome on this investigation, you will always have my sincere and heartfelt respect for treating me like a human being.  Thank you for honoring me as an individual.

Very sincerely yours,

Kathi Ann Stringer


"California Department of Mental Health"




§ 784.37. Restrictions on Applying Restraints and Utilizing Seclusion.

  • (c) Client’s in restraint or seclusion shall be provided all of the following:
    • (2) Regular observation and assessment, which shall include a determination of whether the client meets the criteria for release by authorized staff members, at least every 15 minutes.
    • (3) The observation and assessment shall include face–to–face interaction with the client unless the staff member determines that it is inappropriate or unnecessary to assure that the client is not in distress.
    • (4) Regular range of motion exercise of at least 10 minutes every two (2) hours of restraint. When range of motion is not appropriate, a physician or a psychologist shall document the reason in the client’s record.
    • (5) The client shall be repositioned when appropriate.
    • (6) Prompt and appropriate response to all requests made for assistance and services.

(d) The client shall be released at the time he or she no longer meet

§ 784.38. Restraint and Seclusion—Documentation and Reporting Policies and Procedures.

  • (a) Care provided to a client in restraint or seclusion shall be documented in the client record.

o         (1) The policies and procedures of the mental health rehabilitation center shall describe the manner in which this documentation shall be entered in the client record.

    • (2) Notations, check marks, and flow charts are allowable if the chart provides opportunity for narrative descriptions by staff, when appropriate, and when sufficient to provide all the necessary information.
  • (b) The documentation shall include, but not be limited to, all of the following:
    • (1) Clinical condition, circulation, condition of limbs, and attention to hydration, elimination, and nutrition needs.
    • (2) Behavioral assessments.
    • (3) Justification for continued use of restraint or seclusion, the types of behaviors that would facilitate release and evidence that this information was communicated to the client, along with his or her
    • response, if any.
    • (4) Time placed in and time removed from restraint or seclusion.
    • (5) 15–minute observations and assessments.
    • (6) When face–to–face interaction does not occur, documentation of the reason why that interaction was inappropriate or unnecessary and what alternative means were used to determine the client was not in distress.
    • (d) Facilities that use restraint or seclusion, or both, shall have written policies and procedures concerning their use. These policies shall include the standards and procedures for all of the following:
      • (1) Placement of a person in restraint or seclusion, including a list of less restrictive alternatives, the situations in which the use of restraint or seclusion is to be considered and the physician(s) and psychologist(s) who can order its use.
      • (2) Assessment and release, including guidelines for duration of use of specific behavioral criteria for release.
      • (3) Provision of nursing care and medical care, including the administration of medication.
      • (4) Procedures for advocate notification regarding any client restrained or secluded for more than eight (8) hours.
      • (5) Provision of staff training.
  • (e) Facilities that use restraint or seclusion shall implement an oversight process to ensure that all incidents of seclusion and restraint are reviewed and that any incidents or patterns of use which do not  comply with the mental health rehabilitation center’s policies and procedures or other clinical or legal standards are investigated.  This oversight process shall ensure that appropriate policies and procedures are developed and implemented, including training of staff. Consumer input into the oversight process shall be incorporated. NOTE: Authority cited: Sections 5675 and 5768, Welfare and Institutions Code; Section 3 of Chapter 678 of the Statutes of 1994. Reference: Sections 5675 and 5768, Welfare and Institutions Code.
5325.1.  (c) A right to be free from harm, including unnecessary or excessive physical restraint, isolation, medication, abuse, or….

Written on 2/19/03 and Pt Rts called this day – left message.

Added about restraints – Restraints applied incorrectly.  Both arms were restrained adjacent and outward from my body with my elbows bent over each edge of the mattress in a downward position.  After two hours staff released left (L) foot and right (R) hand.  However right (R) foot and left (L) arm was not released and were not rotated for range of motion.  The pain mounted in left (L) shoulder.  I used my right (R) hand to support my left (L) arm to lessen the pain and now my right (R) arm tired also.  The pain went down my neck into my left (L) shoulder. 

Approximately three hours later I screamed for relief and did not receive full range of motion in all extremities at the two-hour mark.  Staff said RN did not leave instructions to rotate and staff refused.  I was screaming for relief.  Staff (x2) seemed satisfied that I was in pain and closed the door.  I kept screaming the regulations for S&R mandated by the State until staff finally opened the door and said they were aware of that law.  Staff restrained my right (R) wrist that was tired from holding up my left (L) arm and restrained my left (L) foot – and released my left (L) hand and right (R) foot.  Staff left the room.  Because one arm had been supporting the other arm, no relief was provided.  The pain continued.  I kept shifting positions on the bed seeking relief.  I tried several positions over a twenty-minute period.  I screamed for relief again.  I screamed that, “If I don’t get relief, I’ll report this to patients’ rights.”  Gilbert held his hand and flat parallel from the floor.  He held his hand high so I could see it though the window.  Then he wavered his hand and made a facial expression stating, “Oh, I’m really scared,” mocking me, taughting me, so it appeared. 

It was no use.  I concentrated and tried to offset the pain in my neck and shoulder but it was impossible.  I screamed again for relief.  Matt opened the door and stated, “You got yourself into this, you wouldn’t stop, now deal with it!”  Matt closed the door.  I couldn’t take it anymore.  I started screaming profanities and began to panic with fear that no one would help me.  I began to have vivid memories of the first time I was in restraints and had went into a full panic attack.  I began crying with the screams.  Matt raised his voice. I could hear him though the door stating, “Calm down because if you don’t stop screaming you will be left in there longer.”  I was panicking.  My heart was pounding.  I felt there would be no end to this pain.  Matt opened the door again and said I was in restraints for only 3 hours and 20 minutes and it was required that I stay in them for a full 4 hours.  I said, “Lupe said if I contracted I would be released.”  Matt indicated that was false and Lupe only said that to calm and relax me, and I had another 40 minutes to go.  I screamed, “So Lupe lied to me then?”  Matt stated, “I don’t know because I wasn’t in the room when she said it.”  His answer confused me and the thought of 40 minutes more in these restraints terrified me.  Would I be able to hang in there that long?  Could I continue to bear the pain?  At least now I had a timeframe to work with so the panic lessened some.  Matt shut the door.  I kept screaming.  He opened the door and said that Norma the charge nurse was aware of the situation and now it was up to her.  He shut the door.  I kept repositioning myself – the pain continued in the lower shoulder area.  Both arms were tired taking turns holding the weight.  It was a dance of pain.  Forty minutes later Norma entered the room and released me.  I glanced at the clock and it was exactly 4:00 PM, so she was apparently aware of my dilemma and timed her entry to the full extent of the painful restraint.  Time: 12:00 noon till 4:00 PM.

 A Call for Speakers:

Did you know that an estimated 100-150 people in psychiatric facilities die in seclusion or restraints every year? There have been 17
restraints/seclusion related deaths since 1999 in California after the
U.S. Centers for Medicare and Medicaid Services (CMS, formerly HCFA) put out standards on the use of restraint and seclusion.

The Office of Senate Research is publishing a Report on Restraint and
Seclusion, which collects all the data, and thinking on the issue in the last few years. It is holding a press conference at the Capitol to release the report.

The organizing folks are looking for a client who has experienced Restraint and Seclusion since 1999 in a California facility. If you have had this experience in this time frame, contact me.

(Off-topic, but related: The South Region's project this year is educating staff of psychiatric facilities about the experience/issue of restraint and seclusion.)

Sally Zinman

My response: Written by Kathi Stringer

Panic Attack – First Time in Restraints.

I whirled around. Nothing but a flash of bright white lights hazed among a mixture solid gloss walls. Hands, they were everywhere. Grabbing limbs tossing me flat on my stomach, pressing me tight against the mattress. I couldn't move and was confused as to what was happening. My legs were tugged downward toward the end of the cot. Leather was flopped around my wrists and tighten in their vertical slots into a metal lock. A hot rush of blood alerted my senses purging the synaptic responses and throwing them into a different dimension. This is hell, I thought I'm on my way to hell. So this is what a violent death this like, my heart must be failing as the eyes wanted to roll back into the skull.

Their voices murmured to one another as they vacated chamber. One stayed behind. She was kind.

"Something's happening to me!" I screamed. "Stop! Don't leave me like this! My heart is thumping so hard; I think I'm dying!"

"Panic" she said. "You are having a panic attack." She positioned herself between the bed and the wall directly above me. "You're in 5-point, 5-point restraint," she said softly trying to offer comfort. It was only a vestige but yet I thought if she should leave I would die alone as my blood still grew hotter. My extremities were narrowly restricted without consideration. "Try to calm down," she soothed. She began to move toward the exit.

"God, please don't leave me like this. I'll die. My body is reacting and I can't make it stop! Maybe if you stay a few more moments I'll be able to breath again." She left anyway. I felt faint from the trauma. If I wasn't crazy before I was surly being driven there at this instant. The room seemed to slowly spin through a jelly moat. Thick. My brain began to collapse, imploding in opposition to every neurotransmitter actively tying to escape its doom.

First Request:



Would you be interested in testifying about your experience at this Press Conference?

I can submit your name as an interested person. The planning group for the press conference will make the decision of who will present. Some of us are finding potential presenters.

It would be 3 -5 minutes at the Press Room at the Capitol.

Thank you for sharing your experience with me.


Second Request:


I have told the person organizing the press conference about you.

She asked if I would again ask you if you would participate in the press event.

Specifically, without sharing it with her, I told her about the moving

description you wrote of being restrained. She responded that you could just read the description, and not respond to questions.

She also suggested that if you did not feel safe enough to participate in the press conference, would it be OK to add your experience to a vignette of client experiences with restraint and seclusion and give your name to the press as a contact.

I completely respect your feelings of not being ready to go public with your experience. Any decision you make will be respected, by me and this person, who, incidentally works for the California Senate Office of Research.

In Support,

Sally Zinman

Response: Permission Granted

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