One of the most difficult things for a person to do is to see their loved one in a medical setting with physical restraints on their wrists, ankles, or across their body. Physical restraints (as opposed to medication restraints) typically come in the form of wrist restraints, leg restraints and vest restraints. Physical restraints are defined as “any device, material or equipment attached to or near a person’s body and which cannot be controlled or easily removed by the person and which deliberately prevents or is deliberately intended to prevent a person’s free body movement to a position of choice and/or a person’s normal access to their body.” (Re-quoted in C. Gastmans & K. Milisen, Use of physical restraint in nursing homes: clinical-ethical considerations, J. Med. Ethics 2006 (Mar. 32(3): 148-152, 2005)).
In nursing homes, restraints are used in two primary settings – when a patient is in bed to prevent him or her from falling out of bed, and when a patient is in a wheelchair to prevent the patient from getting out of the chair and falling. While it is less common in nursing homes, restraints have also been utilized at times to prevent a patient from removing an IV line, a catheter, or a feeding tube. In the rarest of cases, restraints may also be utilized when a patient is dealing with behavioral issues or psychological issues in order to control that patient until a medication has had time to become effective.
In the past, restraints were over-utilized by many nursing homes and became a method of avoiding having to watch or monitor patients. The belief by some is if the patient was restrained, then fewer staff hours were required to watch a patient to keep him or her from falling or wandering about the facility. The use of restraints also came with its own set of risks, with some patients being injured because of the very thing intended to protect them. This over-utilization and added safety risks, through the years, came under greater scrutiny, and as a result the use of restraints has been greatly minimized as the standards and medical practices with respect to this equipment have evolved.
Federal law (see 42 CFR § 483.13) and most states also address the use of restraints in nursing homes. Generally speaking, the use of restraints in nursing homes is prohibited unless the patient’s medical condition requires the use of restraints. Using restraints for the convenience of the facility or as punishment of the patient is a violation of the law and is never acceptable practice.
Whatever form of restraint a nursing home uses, it is essential that the nursing staff be adequately trained and educated on the application and the risks of these devices. Vest restraints must be properly placed on the patient and the tie-off to the bed or chair must be done appropriately. If not properly placed on the patient, the patient can attempt to slide out of the vest and become entangled. There have been reports of some patients getting their necks caught in the vest and, while struggling to free themselves, literally choking from the vest.
Wrist restraints should be made of soft, cottony material. The restraints should be applied in such a way to stay on while eliminating the risk of injury the wrists, such as causing breaks, circulatory flow issues, and the like. The same is true for leg restraints, which are most often applied around the ankles. Pedal pulses (at the ankle) are essential to maintain lower-limb blood flow and the return of blood to the heart. If the leg or wrist restraints interfere with the movement of blood through the body, the results can be fatal.
Too, older patients are at a heightened risk of developing skin tears and sores. Sores to the body in elderly patients can be a nightmare to treat and heal, and any open wound greatly increases the risk of bacterial infection and resulting sepsis in the patient. Anyone who develops sepsis is in danger of death, and this risk is increased astronomically in the elderly, who often have compromised immune systems to begin with.
Gastmans and Milisens, in their article referenced above, have identified other risks of physical restraints to include: respiratory complications; urinary incontinence and/or constipation; malnutrition; decrease of ADLs (activities of daily living) and increased dependence upon others; loss of balance; increased agitation; and increased risk of premature death. These authors concluded that, in many cases, the use of the restraints heightened the risk of injury rather than reduced or minimized that risk as intended.
Most nursing homes have changed their names to “rehabilitative” facilities, and the implication is that a primary goal of the nursing home is to help with physical, mental and cognitive rehabilitation. The use of restraints does not promote these goals if overused or if used long-term. The less a person uses his or her muscles, the more the muscles atrophy and contract, and the less physical strength the person has. Likewise, bones become more fragile and weakened over time if the arms and legs are not moved or if a person spends too much time a wheelchair or a bed, restrained with limited movement. This increases the risks of breaks or fractures, which can create a host of medical issues. Needless to say, extensive use of restraints also increases mental and cognitive decline, and the use can be demeaning and humiliating in some instances, leading to depression of the patient or simply the loss of will to live.
According to Thomas A. Sharon, RN, MPH, an author and expert in nursing, public health and patient safety, a family member who finds their loved one in restraints should do the following:
Ask the nurse to explain the rationale for using the restraints; ask for a copy of the written policy and procedure pertaining to the particular restraint being used; go over the requirements with the unit charge nurse; stay with the patient as much as possible; and give frequent loving reassurance even if the patient does not appear to understand.
There are also some other things that Mr. Sharon encourages. He says that family members of patients should:
• Demand the right to see all the care plans related to safety and accident prevention.
• Review those plans with the nurses.
• Take the opportunity to voice approval or recommend alternatives.
It is also important to understand that oftentimes there are viable and safer alternatives to the use of physical restraints. For example, side rails in beds, with or without bumpers, may be used to keep patients from getting out of bed and injuring themselves. Angular wedges or chairs that tilt a patient slightly backward may also prevent or greatly reduce the chance that a patient may get out of a chair and injure him or herself. Bars or tray tables on chairs also reduce the risk that a patient will try to get up on his or her own.
Of course, there is no substitute for one-on-one monitoring of a patient, whether or not physical restraints are utilized. If you need more information on this subject, contact Ben Locklar, a lawyer in our Personal Injury/Products Liability Section, at 800-898-2034 or by email at Ben.Locklar@beasleyallen.com. Ben handles nursing home litigation for our firm.
Sources: Virginia Nursing Home guidelines and http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564468/
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