Restraint Use

                                                      RESTRAINTS

WHAT ARE RESTRAINTS?

Physical Restraints: Any object or device that restricts movement or the ability to get to a part of the body.  Usually a specialty device is used.  Examples include vest restraints, waist belts, geri-chairs, hand mitts, and lap pillows.

Chemical Restraints: Psychoactive drugs used to treat behavioral symptoms in place of good care.

WHY ARE RESTRAINTS USED?

·        Facilities or family members believe (usually mistakenly) that they ensure safety;

·        As a substitute for adequate numbers or levels of staff;

·        Facility fear of liability.

WHO IS USUALLY RESTRAINED?

·        A resident with a history of falls, aggression, or wandering;

·        A resident with a pre-existing injury or medical condition which makes walking or standing unsafe.

WHAT ARE THE GOOD OUTCOMES OF RESTRAINT USE?

Physical Restraints: In rare instances a restraint may enable a resident to do more, for example, a half bed rail may allow a partially paralyzed person to turn over; a seat belt may help double amputees to remember that they cannot walk on missing legs (they may have the feeling that their legs are still there).

Chemical Restraints: A resident’s distressing behavioral symptom, such as depression, might be treated with a psychoactive drug when measures such as increased activities or talking with a social worker do not work.

WHAT ARE THE POOR OUTCOMES OF RESTRAINT USE?

Accidents involving restraints which may cause serious injury.

Changes in body systems which may include: poor circulation, chronic constipation, incontinence, weak muscles, weakened bone structure, pressure sores, increased agitation, depressed appetite, increased threat of pneumonia, increased urinary infections, or death.

Changes in quality of life which may include: reduced social contact, withdrawal from surroundings, loss of autonomy, depression, increased problems with sleep patterns, increased agitation, or loss of mobility.

CURRENT LAWS and REGULATIONS WHICH GOVERN RESTRAINT USE

·        The Nursing Home Reform Act of 1987 states the resident has the right to be free from physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident’s medical symptoms.

·        This law also includes provisions requiring:

·        quality of care -- to prevent poor outcomes of care;

·        assessment and care planning -- for each resident to attain and maintain her highest level of functioning;

·        residents be treated in such a manner and environment to enhance quality of life.

STRATEGIES FOR REDUCING RESTRAINT USE

            Although reducing restraint use can be frightening for some families and staff members, there are many facilities that have successfully committed to a restraint-free environment without an increase in resident injuries.  Committed families and staff members working together to follow an individualized care plan can make this a reality which can benefit both residents and caregivers.  In fact, research confirms that non-restrained residents require fewer minutes of direct nursing care when compared to similar residents who are restrained. However, a Federal government report notes that in order to be effective, restraint reduction activities must involve the whole facility, including “administrators, nursing directors, physical and recreational therapists, service delivery staff including nursing assistants, and housekeeping personnel.” [1] (p. 354) Family members and advocates should expect and insist that the facility be responsible and proactive in:

·        Completing a comprehensive resident assessment: Assessments gather information about how well residents can take care of themselves and when they need help.  They identify strengths and weaknesses, plus lifelong habits and daily routines.  

·        Formulating an individualized care plan: Based on strengths and weaknesses identified on assessment, a care plan is developed for how staff will meet a resident’s individual needs.  It should describe what each staff person will do and when it will happen.  The care plan is designed at a quarterly care-planning conference, attended by staff, residents, and their families.  The care plan should change as the resident’s needs change.

·        Training staff to assess and meet an individual resident’s needs -- hunger, toileting, sleep, thirst, etc. -- according to the resident’s routine rather than the facility’s routine.

·        Supporting and encouraging professional caregiving staff to think creatively of new ways to identify and meet residents’ needs.

·        Providing a program of activities enjoyed by the resident, such as exercise, outdoor time, or small jobs agreed to and enjoyed by the resident.

·        Providing the resident with companionship, including volunteers, family, and friends.

·        Creating a safe environment with good lighting, mattresses on the floor to cushion falls out of bed, appropriate, comfortable seating, alarms, clear and safe walking paths inside and outside the building.

·        Making permanent staff assignments and promoting staff flexibility to meet residents’ individualized needs.

If the nursing home is resistant to restraint reduction, you may want to suggest that they contact NCCNHR for materials which provide information on specific programs for reducing restraint use including:

·        Restorative care including walking, and independent eating, dressing, bathing programs;

·        Wheelchair management program -- to assure correct size, good condition, and appropriate seat cushions;

·        Individualized seating program--chairs, like wheelchairs, should be tailored to individual needs;

·        Specialized programs for residents with dementia, designed to increase their quality of life;

·        Video visits - videotaped family visits when families live far away;

·        Wandering program -- to promote safe wandering while preserving the rights of others;

·        Preventive program based on knowing the resident -- to prevent triggering of aggressive behavioral symptoms and using protective intervention as a last resort;

·        Toileting of residents based on their schedules rather than on staff schedules.

If you are interested in learning more, NCCNHR has several publications that may be of interest.  Call 202.332.2275 for a publication list or visit the website at http://www.nccnhr.org.  Prices listed do not include shipping or handling.

• Nursing Homes: Getting Good Care There, Cost: $11.95