Restraint Alternatives and Safe Restraint Use Chapter 14 Restraint Alternatives and Safe Restraint Use Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

The Centers for Medicare & Medicaid Services (CMS) Some persons may present dangers to themselves or others (including staff). The Centers for Medicare & Medicaid Services (CMS) have rules for using restraints. The rules apply to agencies receiving Medicare and Medicaid funds. Restraints may be used only to treat a medical symptom or for the immediate physical safety of the person or others. Restraints may be used only when less restrictive measures fail to protect the person or others. Restraints must be discontinued at the earliest possible time. Like the Omnibus Budget Reconciliation Act of 1987 (OBRA), CMS rules protect the person’s rights and safety. All patients and residents have the right to be free from restraint. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

The Centers for Medicare & Medicaid Services (CMS) (cont’d) The CMS uses these terms. Physical Restraint—any manual method or physical or mechanical device, material, or equipment attached to or near the person’s body that he or she cannot remove easily and that restricts freedom of movement or normal access to one’s body. Chemical Restraint—any drug used for discipline or convenience and not required to treat medical symptoms. The drug or dosage is not a standard treatment for the person’s condition. Freedom of Movement—any change in place or position of the body or any part of the body that the person is able to control. Remove Easily—the manual method, device, material, or equipment used to restrain the person can be removed intentionally by the person in the same manner it was applied by the staff. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

History of Restraint Use Restraints were once thought to prevent falls. Research shows that restraints cause falls. Injuries are more serious from falls involving restrained persons. Restraints also were used to prevent wandering or interfering with treatment. Restraints were viewed as necessary devices to protect a person. However, they can cause serious harm, even death. Falls occur when persons try to get free of the restraints. Restraints were often used for persons who showed confusion, poor judgment, or behavior problems. Older persons were restrained more often than younger persons were. Review the contents of Box 14-1 on p. 197 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

History of Restraint Use (cont’d) The Food and Drug Administration (FDA), state agencies, and The Joint Commission (TJC) also have guidelines for restraint use. They require considering or trying all other appropriate alternatives first. Every agency has policies and procedures about restraints. Agency policies and procedures about restraint use include: Identifying persons at risk for harm, harmful behaviors, restraint alternatives, and proper restraint use Staff training Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Restraint Alternatives Often there are causes and reasons for harmful behaviors. Knowing and treating the cause can prevent restraint use. Restraint alternatives for the person are identified. They become part of the care plan. If restraint alternatives do not protect the person, the doctor may need to order restraints. The nurse tries to find out what the behavior means. This is very important for persons with speech or cognitive problems. Review the questions on p. 197 in the Textbook. Review the contents of Box 14-2 on p. 198 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Safe Restraint Use Agencies must follow: CMS, OBRA, FDS, and TJC State laws Restraints are not used to discipline a person. Restraints are not used for staff convenience. Restraints are used only when necessary to treat a person’s medical symptoms. The CMS defines a medical symptom as an indication or characteristic of a physical or psychological condition. Discipline is any action that punishes or penalizes a person. Convenience is any action that: Controls or manages the person’s behavior Requires less effort by the center Is not in the person’s best interests Symptoms may relate to physical, emotional, or behavioral problems. Sometimes restraints are needed to protect the person or others. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Safe Restraint Use (cont’d) According to the CMS, physical restraints include these points. May be any manual method, physical or mechanical device, material, or equipment Is attached to or next to the person’s body Cannot be easily removed by the person Restricts freedom of movement or normal access to one’s body Drugs or drug dosages are chemical restraints if they: Control behavior or restrict movement Are not standard treatment for the person’s condition Physical restraints: Are applied to the chest, waist, elbows, wrists, hands, or ankles Confine the person to a bed or a chair Prevent movement of a body part Some furniture or barriers also prevent freedom of movement. Drugs cannot be used: For discipline or staff convenience If they affect physical or mental function Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Safe Restraint Use (cont’d) Enablers A device that limits freedom of movement but is used to promote independence, comfort, or safety Some devices are both restraints and enablers. When the person can easily remove the device, and it helps the person function, it is an enabler. Enabler vs. Restraint A person chooses to use a geriatric chair with a lap-top tray for meals and writing. If used to limit freedom of movement, it is a restraint. A person chooses to have raised bed rails. The person uses the bed rails to move in bed and to prevent falling out of bed. The bed rails are enablers, not restraints. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Safe Restraint Use (cont’d) Complications of restraint use Injuries occur as the person tries to get free of the restraint. Injuries occur from using the wrong restraint, applying it wrong, or keeping it on too long. The most serious risk is death from strangulation. There are also mental effects. Restraints affect dignity and self-esteem. The Safe Medical Device Act applies if a restraint causes illness, injury, or death. CMS requires the reporting of any death that occurs While a person is in a restraint Within 24 hours after a restraint was removed Within 1 week after a restraint was removed Review the content of Box 14-1 on p. 197 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Safe Restraint Use (cont’d) Legal aspects Laws applying to restraint use must be followed. Restraints must protect the person. They are not used for staff convenience or to discipline a person. A restraint is used only when it is the best safety measure for the person. Restraints are not used to punish or penalize uncooperative persons. Using restraints is not easier than properly supervising and observing the person. A restrained person requires more staff time for care, supervision, and observation. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Safe Restraint Use (cont’d) A doctor’s order is required. The doctor gives the reason for the restraint, what body part to restrain, what to use, and how long to use it. The least restrictive method is used. Restraints are used only after other measures fail to protect the person. Unnecessary restraint is false imprisonment. Informed consent is required. Either the person or his or her representative must give consent before a restraint can be used. Review the contents of Box 14-2 on p. 198 in the Textbook. The care plan must include measures to protect the person and prevent harm to others. Many fall prevention measures are restraint alternatives. You must clearly understand the reason for the restraint and its risk. Review the Focus on Communication: Legal Aspects Box on p. 200 in the Textbook. The person or his or her legal representative must understand the reason for the restraint. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Safe Restraint Use (cont’d) Safety guidelines Observe for increased confusion and agitation. Protect the person’s quality of life. Restraints are used for as short a time as possible. Follow the manufacturer’s instructions. Apply restraints with enough help to protect the person and staff from injury. Observe the person at least every 15 minutes or as often as noted in the care plan. Remove or release the restraint, reposition the person, and meet basic needs at least every 2 hours or as often as noted in the care plan. Follow the care plan. The restrained person must be kept safe. Review the contents of Box 14-3 on pp. 201-202 in the Textbook. The care plan must show how to reduce restraint use. You could be negligent if you do not apply or secure a restraint properly. Restraints are dangerous. Injury and death can result from improper restraint use and poor observation. Review the Focus on Communication: Safety Guidelines Box on p. 201 in the Textbook. Review the Teamwork and Time Management: Safety Guidelines Box on p. 201 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Safe Restraint Use (cont’d) Report and record the following: The type of restraint applied The body part or parts restrained The reason for the application Safety measures taken The time you applied the restraint The time you removed or released the restraint and for how long The person’s vital signs The care given when the restraint was removed or released Information about restraints is recorded in the person’s medical record. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Safe Restraint Use (cont’d) Skin color and condition Condition of the limbs The pulse felt in the restrained part Changes in the person’s behavior Complaints of discomfort; a tight restraint; difficulty breathing; or pain, numbness, or tingling in the restrained part. Report these at once. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Safe Restraint Use (cont’d) Applying restraints Restraints are made of cloth or leather. Cloth restraints (soft restraints) are applied to the wrists, ankles, hands, waist, and chest. Leather restraints are applied to the wrists and ankles. Wrist restraints (limb holders) limit arm movement. Hands are placed in mitt restraints. They prevent finger use and are used for the same reasons as wrist restraints. Most are padded. The belt restraint is used: When there is risk of injury from falls For positioning during medical treatment Cloth restraints are mitts, belts, straps, jackets, and vests. Leather restraints are used for extreme agitation and combativeness. Wrist restraints may be used when the person: Is at risk for pulling out tubes used for life-saving treatment Is at risk for pulling at devices used to monitor vital signs Scratches at, pulls at, or peels the skin, a wound, or a dressing The person in a belt restraint cannot get out of bed or out of a chair. A roll belt allows the person to turn from side to side or sit up in bed. The person can release the quick-release–type belt restraint. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Safe Restraint Use (cont’d) Vest and jacket restraints are applied to the chest. A jacket restraint is applied with the opening in the back. The straps of vest and jacket restraints cross in the front. Vest and jacket restraints are never worn backward. The restraint is always applied over a garment. Vest and jacket restraints have life-threatening risks. You are advised to only assist the nurse in applying them. The nurse should assume full responsibility for applying a vest or jacket restraint. Never use force to apply a restraint. The person in a vest or jacket restraint cannot turn in bed or get out of a chair. Review the Focus on Children and Older Persons: Applying Restraints Box on p. 207 in the Textbook. Review the Focus on Communication: Applying Restraints Box on p. 207 in the Textbook. Review the Delegation Guidelines: Applying Restraints Box on p. 207 in the Textbook. Review the Promoting Safety and Comfort: Applying Restraints Box on p. 208 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.