Physical Restraints in the Nursing Home

What is a physical restraint?

A physical restraint is any manual method or material device attached, or adjacent to, a resident's body that he/she cannot remove easily. A physical restraint restricts freedom of movement or normal access to one's body. Nursing home staff are responsible for appropriate safe application of restraints, monitoring, periodic release, range of motion of involved body region, and toileting while the restraint is in use.

Restraints are never to be used for discipline or convenience and used only to treat medical conditions in accordance with state and federal regulations. Many hazards are associated with physical restraints including pressure sores, loss of the ability to go to the bathroom independently, depression, increase in anxious behaviors due to limited control of one’s body, and strangulation resulting in death. For these reasons, many facilities have opted to be “restraint-free.”

What are some examples of types of restraints?

• Lap belts
• Lap buddies (if the resident cannot remove them)
• Recliners and gerichairs (with or without a tray) if the resident cannot easily move from the position
• Side rails
• Concave mattresses (that sag in the middle) from which the resident cannot rise
• Tucked or tightly fastened sheets
• Fabric or clothing that restricts movement
• Trays or devices used with a chair that prevent rising
• Orthotic or positioning devices that restrict free movement
• Fabric vest, wrist, pelvic, waist, or mitt devices

What standards of care must nursing staff follow related to the use of physical restraints?

• A thorough assessment that involves multiple departments must be completed before a restraint is applied.
• There must be a written plan of care for restraint use.
• The use of restraints requires a physician’s order.
• The responsible party (if the resident cannot make healthcare decisions) must be notified and give consent for restraint use.
• Use of the least restrictive device (example - a recliner instead of a vest restraint) must be used.
• A documented plan for periodic attempts at reduction or elimination of the restraint should be noted.
• Residents should be checked in their restraint every hour and released and repositioned from their restraint every two hours and documentation should reflect this.
• Staff must be educated about proper restraint use.

What are some times where physical restraints may be applied to treat medical symptoms?

• Behavior problems with risk of serious injury to self or others. Emergency restraints may continue no more than 24 hours without a physician examination.
• A history of serious falls with risk of severe injury
• Neurological or orthopedic condition requiring strict positioning
• Risk of dislodgement of fresh (less than 4 weeks) central line in the neck or chest used for IV therapy or dialysis.
• Using a restraint for several days to allow a confused resident to receive essential intravenous fluids or medications.
• Using positioning devices such as special seat cushions that help the resident to sit properly, but that may not allow the resident to get up without help (ex. wedge cushion).

Questions you can ask the nursing home about physical restraint use:

• Are you a restraint-free nursing home?
• How does the nursing home decide when restraints are needed, or decide that less restrictive alternatives are not workable?
• How does a nursing home determine whether a resident's restraints are still necessary?
• How does the nursing home know the restraint is effective?
• How does the nursing home watch for complications of restraint use?
• Does the nursing home have a restraint reduction program or policy?
• Does the staff help the restrained resident move as much as is practical?

Resources

The National Consumer Voice for Quality Long-Term Care

MedQIC Qualitynet