1. RESTRAINT ALTERNATIVES AND SAFE RESTRAINT USE Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Chapter 14

2. The Centers for Medicare & Medicaid Services (CMS) Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 2  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.

3. The Centers for Medicare & Medicaid Services (CMS) (cont’d) Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 3  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.

4. History of Restraint Use Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 4  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.

5. History of Restraint Use (cont’d) Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 5  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.

6. Restraint Alternatives Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 6  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.

7. Safe Restraint Use Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 7  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.

8. Safe Restraint Use (cont’d) Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 8  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

9. Safe Restraint Use (cont’d) Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 9  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.

10. Safe Restraint Use (cont’d) Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 10  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 While a person is in a restraint Within 24 hours after a restraint was removed Within 24 hours after a restraint was removed Within 1 week after a restraint was removed Within 1 week after a restraint was removed

11. Safe Restraint Use (cont’d) Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 11  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. 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. 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. Restraints are not used to punish or penalize uncooperative persons.

12. Safe Restraint Use (cont’d) Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 12  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.

13. Safe Restraint Use (cont’d) Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 13  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.

14. Safe Restraint Use (cont’d) Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 14  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

15. Safe Restraint Use (cont’d) Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 15  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.

16. Safe Restraint Use (cont’d) Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 16  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

17. Safe Restraint Use (cont’d) Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 17  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.

18. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slid e 18