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"FREE THE OLD DOMINION" - Fact Sheet on Minimizing Use of Physical Restraints
What Are Physical
Restraints?
Any manual method or physical or
chemical device, material or equipment
attached or adjacent to a resident's body that the individual cannot
remove easily which restricts freedom of movement or normal access to
one's body. 42 C.F.R. §483.1(a).
What Does The Federal Law
Say?
Nursing facility residents have the right
to be free from ANY physical restraints imposed for discipline or
convenience and not required to treat the resident's medical
symptoms. Before restraining a resident, the facility must
demonstrate the presence of a specific medical symptom that would require
the use of restraints and how the use of the restraint would: (1) treat
the cause of the symptom and, (2) assist the resident in reaching the
highest level of physical and psychosocial well-being.
What Are The Known Risks Of Using
Physical Restraints?
Everyday restraining devices, vests,
belts, mitts, jackets and others, are used on as many as 500,000 frail
aged and disabled persons. These devices are intended to protect
them from falls and other accidents. But they also cause injuries
and accidents, many even fatal ones. Restraints are accident
hazards that increase the chance of serious injuries and death.
Experts estimate that as many as 200 people die each year because they
strangle or suffocate in restraints even if the device is applied
correctly. Providers have been successfully sued for these injuries
and deaths.
Other known harm associated with the use of restraints include avoidable
decline in ability to walk, decrease muscle tone, contracture, increased
chance of pressure sores and infections, delirium, agitation, behavioral
symptoms, confusion, depression, constipation and incontinence.
What Is The Standard Of Care
Regarding The Use Of Physical Restraints?
A combination of a more realistic
appraisal of the legal risks, federal regulatory mandates, enhanced
provider awareness, leadership by professional, trade and advocacy
organizations and the fact that many long term care providers have
successfully eliminated physical restraints from their facilities is
changing the professional and, hence, the legal standard of care.
See, Kapp, M., Nursing Home Restraints and Legal Liability, J. Legal Med.
(1992). Similarly, JCAHCO standards emphasize the physical
restraints should be used only as a last resort for an identified
problem.
Don't I Need To Use Restraints
To Protect The Resident From Falls Or Injuries Due To
Wandering?
"There is little or no evidence that
restraints prevent fall injuries or that removing them causes such
injuries. Ironically, the injury risks (and confirmed legal
liability) of using restraints are numerous and well
documented." Kapp, M., Physical Restraints in Hospitals: Risk
Management's Role, Health Care Risk Management (1994). There have
been some very large judgment against nursing homes as a result of
injuries and deaths caused by the improper use of restraints. In
some cases and in some states misuse of restraints is a crime.
Won't We Be Sued If We
Don't Use Restraints?
Few legal precedents support nursing
facilities based on a failure to restrain. The nursing facility's
duty is to provide protective oversight for those residents who are
"safety dependent" for any number of reasons extends far beyond
merely tying residents to thorough observation and assessment of the
individual's condition, implementation of the best restrictive approaches
to address the underlying causes of specific, identified behaviors and
periodic evaluation of the resident's responses. The best defense
is to provide good care.
What If The Family
Insists On A Restraint?
The facility may not use restraints in
violation of federal regulation solely because a family member or
surrogate has approved or requested them. See, DHHS Medicaid State
Operations Manual, 42 C.F.R.§483.13(a) Guidance to Surveyors at PP-44
(1995). As a practical matter, families, acting from a well-placed
concern for the safety of their loved one will need education, support
and guidance to understand the dangers of restraint use and to accept
that there are less restrictive alternatives that will accomplish the
goal of keeping their family member safe without the harm necessarily
caused by restraints.
How Do We Begin To
Minimize The Use Of Physical Restraints?
Reduction of physical restraints needs to
be a gradual and systematic process. It does not happen
overnight. Expect plateaus and periodic reassessment of your
commitment and methods. In general, the operational stages of a
successful restraint reduction program include: (1) establishing a
commitment to restraint reduction from the highest to the grass roots
level of the organization; (2) reducing restraints on existing residents
and resolving to let NO new restraints into the facility; (3) maintaining
a restraint-free home. DHHS, Office of the Inspector General,
Minimizing Restraint Use in Nursing Homes, 1992. According to
Dunbar & Rader, specific methods for a successful restraint reduction
program include:
- Individualized assessment and care relationships and rapport between caregivers and residents permanent assignments of nursing staff comprehensive, interdisciplinary plans of care regular meetings of the restraint reduction task force educated staff and families wholehearted administrative support stability among leadership staff access to ongoing education and consultation a homelike environment.
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