Elders and their families are rightfully concerned about the use of restraints in long-term care. Perhaps they have visited nursing homes or other custodial facilities for memory-impaired seniors and they've seen patients in restraints. They also may have had family members who were restrained in a long-term care facility.
What Are Restraints?
Restraints are any items that are used to prevent movement of a patient. Straps, belts, restrictive vests, cuffs, and special chairs or bedside rails are restraints. Other items can be used as restraints, even if they were not originally designed for that purpose. The classification of an item as a restraint depends on the purpose for which it is used. Any item that is used to restrict a patient's movement can be considered a restraint. A bed rail could be considered an assistive device to allow a patient to turn in bed or get out of bed; however, if that same bed rail keeps the patient from getting out of bed, it would be considered a restraint.
Restraints in Long-Term Care
Until very recently, it was not uncommon for staff people in long-term care facilities to restrain patients for a number of reasons. Concern that patients might hurt themselves or someone else was a leading reason for restraint. However, it was not unusual for overworked nursing staff members to restrain patients to simply keep them from wandering or to keep them from being a nuisance.
In the past 20 years, researchers have completed a number of studies that indicate that restraints are detrimental in many ways. Personnel at some facilities have been reluctant to make changes, because they see restraints as a way to prevent injuries. Restraints can prevent falls and can prevent physical assaults on nursing staff and other patients. Restraints can also result in many of the following consequences:
- Social isolation
- Incontinence and chronic constipation
- Pressure (bed) sores
- Emotional problems
- Loss of ability to walk
- Loss of ability to perform simple tasks such as bathing, grooming, self-feeding, and use of a toilet
In fact, restrained patients sometimes hurt themselves trying to escape from or remove restraints.
Since October of 1990, nursing facilities that receive Medicare or Medicaid funding have had to observe federal rules on the use of restraints in long-term care.The rules that have evolved over the years since then were finalized in 2006 by the U.S. Department of Health and Human Services. Facilities that receive payments have had to modify their use of restraints. To apply restraints to a patient, the care facility must first:
- Obtain a physician's order for the restraints
- Notify the patient's family that restraints will be used and why
- Use as little restraint as possible
- Assure that the patient's needs for nutrition, hydration, hygiene, and safety are assessed and addressed on a regular basis and addressed appropriately
- Release the restraints at regular intervals, check movement, and provide range of motion exercise
- Assess the need for the restraints on an on-going basis and lessen or remove the restraints as appropriate
Through staff education, long-term care facilities are working to comply with these guidelines. Even proprietary facilities that do not receive Medicare or Medicaid monies are complying with these rules because rules written by state licensing boards tend to fall in line with federal guidelines. There will always be some facilities, however, that are not compliant. Good care costs money, and more nursing staff members are needed to monitor and care for patients who are not restrained.
If someone in your family is in restraints in long-term care, you will want to monitor compliance with the guidelines for use of restraints. If the rules are not being followed, you do have recourse. First, contact the head nurse responsible for the care of your family member. If the issue is not resolved, contact the facility's administrator and let him or her know that you are knowledgeable about the federal regulations.
If after you've made these contacts, you are not satisfied with the response, contact the state organization responsible for care facility regulation and report the problem. They will investigate the problem and ensure that the facility complies with the rules. Because of the federal rules, even if your family member is in a Medicare or Medicaid facility, you have some clout because non-compliant organizations risk losing their funding if they are not compliant.
Ongoing changes in federal rules assure that long-term care patients and their families have rights that can be enforced when it comes to the application of restraints. For instance, facilities will be more innovative in assuring patient safety by using electronic bracelets to limit wandering patients, giving appropriate medication to calm agitated patients, and providing other non-restrictive nursing interventions as an alternative to restraints.