Virginia Restraints Reduction Initiative
"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.