WASHINGTON — In a management advisory memorandum, Inspector General William Blier raised serious concerns about the Federal Bureau of Prisons’ (BOP) use of restraints, finding that unclear policies may endanger the health and safety of incarcerated individuals.
The Office of the Inspector General (OIG) reported that BOP policies appear to neglect the medical and psychological wellbeing of incarcerated people, exposing them to abuse. A lack of surveillance during prolonged restraint has led to severe and lasting injuries such as amputations, scarring and carpal tunnel syndrome.
Although BOP’s Use of Force policy prohibits the use of restraints in a manner that causes “unnecessary physical pain or extreme discomfort,” the OIG has received repeated allegations of abuse, mistreatment and injury linked to restraint use—particularly four-point restraints.
In a memorandum to BOP Director William Marshall, Blier made six recommendations to address the policy shortcomings. His proposals are intended to clarify restraint guidelines, better protect incarcerated people, prevent staff misconduct and safeguard staff from false allegations.
The OIG identified multiple systemic concerns, including lack of clarity on use of force, improper application of restraints, insufficient 15-minute and two-hour checks, inadequate medical and mental health assessments, poor communication with regional offices, prolonged restraint durations, and incomplete after-action reviews.
The OIG also criticized the absence of a clear definition for “four-point restraints” (used to restrain both arms and legs) and inadequate protocols for inmates restrained by other means. The report emphasized that not all four-point restraints involve beds, leaving open the possibility for unsafe and prolonged confinement. Current policies lack required video or audio recordings, undermining oversight and documentation.
To address these issues, the OIG issued six recommendations. The BOP should clearly define “four-point restraint” and provide detailed instructions for restraint checks, including 15-minute and two-hour checks, and for medical and psychological evaluations of those not in four-point restraints.
BOP should update its procedures to limit prolonged restraint use and reduce injury risks. These revisions should enhance staff training, clarify when to use and remove restraints, monitor circulation, involve psychology staff in behavior management planning, and require more regional oversight.
BOP should also mandate video and audio recordings of two-hour lieutenant checks and ensure fixed camera coverage outside cells. The OIG advised expanding documentation forms to include space for detailed behavior and condition notes, with added checkboxes to ensure complete reporting.
Finally, BOP should revise policies for medical staff, encouraging greater detail in documentation and, when feasible, supplementing reports with photos or recordings to capture injuries, bathroom access and food consumption.
In response, Director Marshall agreed with all six recommendations, stating the BOP is “committed to addressing these issues and implementing meaningful improvements.” He called the findings “a crucial opportunity to enhance agency practices and ensure the humane treatment of all inmates.”
