Counting, Using and
Reducing Physical Restraints
of BQA 98-003 (PDF, 42 KB)
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DATE: April 21, 1998 DSL-BQA-98-003
TO: Nursing Homes NH 2
FROM: Judy Fryback, Director, Bureau of Quality Assurance
Example of Restraint Usage
Frequently Asked Questions About Physical Restraints
According to figures from the Health Care Financing Administrations data system,
Wisconsin ranks second highest among the 50 states in the percentage of nursing home
residents who are physically restrained. Year-end 1997 data shows that 26% of residents in
Wisconsins skilled nursing facilities are physically restrained compared to a
national average of 16%.
Federal tag F221 [42 CFR 483.13(a)] requires that residents be free from physical
restraints imposed for the purposes of convenience or discipline and not required to treat
a medical symptom. During 1996, the Bureau of Quality Assurance (BQA) cited deficiencies
of F221 at 9% of Wisconsins nursing homes. This was the same as the national
average. During 1997, the BQA cited a deficiency at F221 at 19% of the nursing homes that
we surveyed. In both 1996 and 1997 we cited other facilities at F272 [42 CFR 483.20(b)]
for not comprehensively assessing either the need for a restraint or the type of
The purpose of this memo is:
To provide information about what a restraint is and how to count residents who are in
restraints. (This is to correct possible inaccuracies in identifying what is or is not a
physical restraint, which may partly account for Wisconsin's high use of physical
To inform you of our expectations for compliance with F221 and the restraint
requirements in Chapter 50, Wisconsin Statutes, and Chapter HFS 132, Wisconsin
Administrative Code for Nursing Homes.
To provide information about the types of deficient practices we have identified in our
citations at F221 (restraints), F272 (comprehensive resident assessment), and F324 ([42
CFR 483.25(h)(2)], adequate supervision and assistance devices to prevent accidents).
To clarify any misunderstandings that may have developed about restraint use or the
reduction of restraints. This includes the misperception that facilities must be
restraint-free and that residents who appear as examples on our restraint citations must
be completely out of restraints by the revisit.
To clarify our expectations when families or guardians insist on using a restraint.
What is a restraint? What should you count as a restraint? The federal
government defines a physical restraint as "any manual method or physical or
mechanical device, material, or equipment attached or adjacent to the residents body
that the individual cannot remove easily which restricts freedom of movement or normal
access to ones body." Similarly, sec. 50.09(1)(k), Wis. Stats., defines a
physical restraint as including, but not limited to, "any article, device, or garment
which interferes with the free movement of the resident and which the resident is unable
to remove easily, and confinement in a locked room." The important characteristics of
a restraint are that (1) it keeps a resident from freely moving or from reaching a part of
his/her body, and (2) the resident cannot easily remove it.
The definitions mean that anything -- a reclining chair, a side rail, a table top, a
sheet that is tied around a resident, a soft chair cushion that prevents a resident from
rising, a physical hold, or a geri-chair -- may or may not be a restraint. It is not
helpful to say that one particular device is a restraint and that another device is not a
restraint. Instead, it is better to think in terms that any device may potentially be a
restraint, depending upon how it is used, on whom it is used, and the effect upon whom it
is used. A side rail may be a restraint for one person, but not another. Even a
lap belt may be a restraint for one person but not for another.
The litmus test for determining if a garment, article, method, or
device is a restraint consists of 2 questions: If the answer is "yes" to both
questions, then the device is a restraint. If the answer to one or both questions is
"no," the device is not a restraint. These questions relate to the resident
and the residents capabilities, not the device.
1. Does the device keep a resident from moving about or from reaching part of
his/her body? Before answering this question, you must first determine what active
movement the resident is voluntarily or involuntarily capable of making, given his/her
functional abilities. Then consider the effect of the device. If the device (not the
residents capabilities) prevents a resident from freely making this movement (e.g.,
purposely or non-purposely moving about or from reaching a part of his/her body), then the
device restricts movement. It may be a restraint. In other words, if the device prevents a
resident from performing an action that s/he would otherwise be capable of performing, it
may be a restraint.
Example of a device that may be a restraint: A wedge cushion or a soft belt keeps a
resident from getting out of a chair. This resident would otherwise be capable of getting
out of the chair by getting up or by actively working to slide out of the chair. The
device may be a restraint, depending on how easily the resident can remove the device
(question 2). This is true even if the resident could not walk once out of the chair.
Examples of devices that are not restraints: (1) A wedge cushion is used as a
positioning device to prevent a resident from passively sliding down in a chair. Even
without the wedge cushion, the resident is not capable of getting out of the chair or
working his/her way down the chair. The device is not a restraint. (In this example, a
soft belt may also prevent sliding, but it may not be the most desirable, or safest,
device. A soft belt often does not prevent a resident from sliding under it, thus creating
a potentially hazardous situation.) (2) A resident repositions him or herself with the
side rail, but the side rail does not prevent the resident from safely and easily getting
out of the side of the bed. The side rail is not a restraint.
If the device is restricting free movement within the context of the residents
capabilities, the second question you must ask is:
2. Is it difficult for the resident to remove the device? If a resident cannot
easily remove a device that is restricting movement the resident would otherwise be
capable of making, the device is a restraint. Conversely, if the resident can easily
remove the device, the device is not restricting the residents movement. We would
not consider the device to be a restraint.
National statistics that depict high restraint use in Wisconsin may be the result of
errors in counting and recording restraints. We believe this because other statistics show
that Wisconsin nursing home residents do not have higher rates than residents in other
states of conditions commonly associated with the negative physical side effects from
restraint use: pressure ulcers, incontinence, urinary tract infections,
immobility. Wisconsin may be over-counting or other states may be under-reporting. It is
important, when calculating the number of residents in restraints, that you do not simply
count the number of residents using a device. Instead, you must look at how the device
affects a residents movement and whether or not the resident can easily remove the
device. When reporting the number of residents in restraints on
the HCFA-672 form, Resident Census and Conditions of Residents, you should count
the number of residents who have a device that restricts movement the resident would
otherwise be capable of making and which the resident cannot easily remove. You should not
simply report the number of residents who have a device. For further
information about whether a side rail is or is not a restraint, please see pages 7 and 8
of this memo.
BQA Expectations. It is our expectation that restraint use will be the exception
rather than the rule. Any physical restraint must clearly benefit the resident, be required
to treat the residents medical symptoms, and lead to the highest practicable level
of functioning for that resident. In no case may a facility use a physical restraint for
purposes of discipline (to punish or penalize a resident) or for convenience (to control
or maintain resident behavior with less effort by facility staff).
BQA expects facilities to use a comprehensive and systematic approach to assess
residents needs. A facility should always use an alternative to a restraint if the
alternative will help the resident achieve his/her highest practicable level of
functioning. If a restraint is the best method for meeting a residents needs,
facilities should use a logical process to determine the least restrictive restraint and
the appropriate conditions for use to minimize application of the restraint. In addition,
staff must re-evaluate the resident to determine if they can meet the residents
needs by using a less restrictive restraint or by approaches that do not include a
One sequence of assessment for determining whether or not a
physical restraint is required might include steps 1-11 listed below.
(1) Staff identify the safety issues/medical symptom for which a restraint is being
considered. Medical symptoms are the manifestations of an underlying illness. They
include both the subjective complaints of the resident as well as the objective data
elicited by an examiner. Medical symptoms alone do not justify the use of a restraint, nor
is there any one medical symptom that should automatically trigger their use. The Health
Care Financing Administration has not, nor does it intend to, issue a list of conditions
or symptoms that qualify as "acceptable" medical symptoms for using a restraint.
This having been said, it is possible that too much attention has been focused on the term
"medical symptom" and whether a particular condition exemplifies an acceptable
medical symptom for using a restraint. Staff must focus on whether a restraint "...
is required to treat a medical symptom." This places the emphasis for
compliance upon the comprehensive assessment of the individual, the assessment of the
underlying factors that contribute to the symptom, and the subsequent decision-making that
led to choosing a physical restraint over other alternatives.
Depending upon the assessment, the treatment of one residents medical symptom
may lead to a completely different course of action than the treatment of another resident
who has the same medical symptom. HCFAs expectation, like ours, is that staff will
comprehensively evaluate each resident on an individual basis to determine what plan of
care will enable the resident to attain or maintain his or her highest level of
functioning and well being. It is the evaluation and assessment process that determines
whether a given symptom is best treated by a physical restraint or some other means.
Contrary to some comments we have heard, it is NOT true that there are only three or
four medical symptoms that qualify for restraint use. It is the assessment of the resident
that ultimately determines whether a restraint is required to treat a symptom.
(2) Staff collect and evaluate data about the circumstances surrounding
the symptom for which a restraint is being considered. When collecting data, staff
might focus on:
preceding events and conditions that may have triggered the symptom;
if the concern is a behavior, such as wandering or getting up at night, what the purpose
of the residents behavior may be (for example, wanting to get up to go to the
bathroom, or thinking s/he needs to go to work)
patterns (e.g., locations and times of the day or night that the symptom occurs); and
the effectiveness of any safety measures being used at the time.
(3) Staff comprehensively assess the resident, with the goal of identifying the
underlying cause of the symptom. As part of the assessment process, staff should
determine whether the underlying cause of the residents symptom(s) is related to
social, environmental, physiological, pharmacological, medical, or other conditions. Staff
may assess the possible influence that each of the following have on the safety issue:
resident posture, gait, vision, sense of balance, blood pressure changes, cognitive
status, safety awareness, physical strength, muscle tone, rehabilitative status, memory,
medications, social history, involuntary movements, activity needs, social skills, and
staff response. (Note: The eight leading risk factors associated with falls are: postural
hypotension; use of sedative, hypnotic and anti-hypertensive medications; use of four or
more medications; unsafe transfer to toilet or bathtub; environmental hazards; gait
impairment; decreased muscle strength and/or range of motion; and balance disturbance.)
We expect that staff documentation will lead us through the assessment process. If the
documentation is not complete, we will ask staff to reconstruct and verbally explain the
(4) Staff identify options and consider the risks and benefits of all identified
treatment options for the individual resident. In light of the comprehensive
assessment, staff will identify the interventions (e.g., social or environmental
modifications, pharmacological changes, medical interventions, etc.) that they might use
and will consider the risks and benefits of each. The purpose of assessing the pros and
cons of each option is to identify the least restrictive approach, in light of specific
individual risks such as previous history of falls, osteoporosis, poor protective
response, coagulation time, etc., that best treats the condition underlying the
residents symptom. If a restraint is used, the positive benefits must outweigh the
possible negative effects of strangulation, pressure sores, incontinence,
loss of bone mass, increased weakness, loss of autonomy, dignity, self-respect, and
independence and functional capacity associated with restraint use. Both the
interdisciplinary team and the resident/legal representative should be comfortable with
the final decision in light of all the risks and benefits.
One key to identifying the best intervention is knowledge of the residents
past and present levels of functioning and what level of functioning the resident might
attain. It also is important that staff know what level of functioning is important to the
resident and how intervention may improve the residents quality of life. If staff
determine, through a comprehensive assessment, that a resident is capable of walking and
this is very important to the resident, the interdisciplinary team may recommend a
strengthening program commensurate with a gradual reduction in the use of restraints. On
the other hand, if the comprehensive assessment shows that the resident is not capable of
walking again and that neurological deficits prevent the resident from understanding this,
the residents highest level of functioning may be sitting safely in a chair.
We expect that staff documentation will lead us through the options that were
considered and the rationale for rejecting non-restraint alternatives. If this has not
been documented, we expect that staff will be able to verbally walk the survey team
through its complete considerations of risks and benefits.
(5) When indicated by the individualized comprehensive assessment, staff attempt
less restrictive alternative measures prior to using a restraint. These may include
environmental modifications (e.g., lowering a bed or getting a different type of bed,
rearranging furniture, reducing glare) diversionary activities (e.g., walking a resident),
or the implementation of care interventions such as hourly toileting or chair/bed alarms.
(6) Except when used in an emergency, staff fully inform the resident or legal
representative of the findings and recommendations of the interdisciplinary team, and of
the risks and benefits of restraints as opposed to other treatment alternatives. The
resident or the legal representative will give informed consent to the use of a restraint
prior to its use. We expect to find documentation that this occurred or that the
decision-maker will verify this if we contact him or her.
Residents, family members and/or a legal representative have the right to actively
participate in the assessment and care-planning process and to make informed choices based
on their understanding of the pros and cons involved in different treatment options.
Family members and legal representatives, however, do not have the right to dictate the
use of a physical restraint when a restraint is not required to treat the residents
medical symptoms. (See page 9.)
The physician orders the restraint. The physician order must include the
residents name, the reason for the restraint and the period during which staff will
apply the restraint [sec. HFS 132.60(6)(b), Wis. Admin. Code]. In addition, the physician
orders any medically necessary therapies or interventions needed to offset the
debilitating effects of a restraint.
Neither state nor federal regulations explicitly require the physician to specify the
type of restraint in his/her order. However, just as a physician would order "Vasotec
5 mg. daily" and would not order "a pill for high blood pressure," the
standard of practice indicates that the physician should specify the type of restraint in
(8) Staff correctly apply the physical restraint and use it only during the time
period ordered. In some cases, staff will use the restraint only in conjunction with
restorative nursing, range of motion, etc.
(9) Staff check a restrained resident as often as necessary but at least every
two hours to reposition the resident and to see that the residents needs are met
[sec. HFS 132.60(6)(f), Wis. Admin. Code]. When restraints are used, it is critical
that the restraint is frequently checked to prevent accidents and deaths from occurring.
(10) Staff document the use of a restraint on each tour of duty on which a restraint
is used [sec. HFS 132.60(6)(g), Wis. Admin. Code].
(11) Staff periodically, but at least quarterly during the MDS review,
re-evaluate the need for the restraint and the type of restraint being used. More frequent
review may be necessary if the residents condition changes. When the need for the
restraint is eliminated, or when the restraint no longer provides a benefit to the
resident, the restraint must be removed.
A facility may apply a physical restraint in a non-emergency only after a
comprehensive, individual assessment leads to a determination that a restraint is required
to treat a medical symptom and to allow the resident to reach his/her highest practicable
level of functioning and well being. Once begun, there should be periodic evaluation of
the need for the restraint and the type of restraint.
In an emergency, a nursing home may use a physical restraint without a physicians
order (sec. HFS 132.31(1)(k), Wis. Admin. Code). We consider an emergency to be an
unpredictable event in which the resident presents an immediate danger to himself or
herself, staff, or other residents. According to HFS 132.31(1)(k), an emergency restraint
may be used up to 12 hours without a physicians order. We expect that physician
contact will occur as soon as possible after the restraint is applied or after the
resident is placed in seclusion.
Section 51.61(1)(i), Wis. Stats., has additional requirements that apply when an
emergency restraint is used on any person who has a mental illness or a developmental
disability or who is protectively placed under chapter 55, Wis. Statutes. For example,
staff must review the residents status every 30 minutes and cannot use emergency
isolation or a restraint beyond one hour unless authorized by the physician.
What deficient practices has BQA been citing in relation to physical restraints?
We have issued citations for the following deficient practices:
Not being able to identify the medical symptom/condition being treated by the restraint.
Using a physical restraint without comprehensively assessing the resident to understand
the underlying basis of the medical symptom and whether staff could treat the symptom
through staff interventions or through changes in the residents environment,
medications, social activities, etc.
Not identifying alternative options to physical restraint use; not evaluating the
risks/benefits of the different options; and, when indicated, not attempting other options
as a first approach to treating the underlying medical symptom/condition.
Not reassessing the continued need for a physical restraint as the residents
Not fully involving residents/families/legal representatives as part of the care
Not checking a restrained resident every two hours or more frequently as indicated by
Not protecting the restrained resident from injury or death as a result of being
Not adequately assessing, supervising, and/or using appropriate assistance devices or
other clinical interventions to increase the safety of residents who had repeated falls.
Not promoting restraint-free periods. This has been cited, for example, when the
resident is in the dining room and continues to be restrained even when being supervised
Restraint Reduction. Since July 1996, there has been an 8%
reduction in the percentage of Wisconsin nursing home residents who are physically
restrained. We applaud the work that led to these results. We would like to make clear
that the goal of restraint reduction is not necessarily to become
"restraint-free." Rather, the goal of restraint reduction is to ensure that:
1. Facilities physically restrain only those residents who require a physical
restraint to treat their condition, and
2. Residents are in the least restrictive restraint for the least amount of time
possible. For example, if a restraint was used in an emergency when a resident posed a
danger to him/herself or others, staff should release the restraint when the resident is
calm and no longer a threat. This also means that staff should promote restraint-free
periods. For example, staff might release a residents chair restraint when the
resident is being directly supervised by staff, as may occur in the dining room or in
A comprehensive assessment of the resident, like that outlined above, is the keystone
for reducing restraints. Facilities attempting restraint reduction or attempting restraint
reduction in response to a citation at F221 should not simply remove a restraint. Physiological changes from long-term restraint use may make the sudden removal
of restraints dangerous. Robert Streimer, Director, Disabled and Elderly Health Programs
Group, HCFA, has stated, "Where residents have been restrained and later found to no
longer need restraints, we believe that it would be irresponsible on the part of a
facility to remove restraints quickly, without a gradual and systematic process to remove
a restraint one step at a time." The sudden removal of restraints (without prior
evaluation for effective alternatives) has led to several resident falls and injuries over
the past several months.
As a result, BQA does not necessarily expect that every resident identified on a
citation at F221 will be completely free of restraints by the time of the revisit. A
facility may determine that a resident first needs to be strengthened before gradually
removing or modifying a restraint. In some cases, the facility may need to make
environmental modifications (such as non-slip, softer surfaces and glare reduction from
windows and doors). The survey team will look for evidence that the facility has worked
with the resident, the attending physician, and the family or legal representative and has
begun implementing a gradual and systematic plan for the eventual reduction of physical
It is less likely that BQA will cite F324 (accident prevention) when a resident falls
after restraint reduction if a facility has followed a logical, systematic
assessment process like that outlined on pages 3-6. In addition, there should be no
avoidable contributing factors (such as medication overdose or untimely response to call
lights). Similarly, BQA is less likely to issue a citation at F324 or F272 (assessment) if,
after each fall, facility staff evaluate the circumstances of the fall, make a thorough
assessment as to what changes, if any, should be made in the residents care and care
plan, and implement these changes.
Side Rails. A side rail may or may not be a restraint,
regardless of whether the resident requests a side rail. You must ask the same two
questions asked on page 2 of this memo to determine if a side rail is functioning as a
restraint. A side rail is a restraint if the resident cannot lower the side rail, and the
prevents a resident, who is otherwise capable of doing so, from safely and easily getting
out of the side of the bed (voluntary movement); or
prevents a resident from falling out of bed, if an assessment shows the resident moves
about in bed to the extent that s/he is capable of falling; or
prevents a resident from involuntarily being "thrown" out of bed because of a
medical condition such as a seizure or because of involuntary movements due to a
The side rail is a restraint if it prevents a resident who would otherwise be capable
of getting out of bed from getting out of bed, even if the resident does not realize s/he
cannot walk once out of bed. (This is true even if the resident has been told to ask for
assistance getting out of bed, but forgets to ask.) Before using a side rail as a
restraint, a facility should work through an assessment like that outlined on
If a side rail meets the definition of a restraint, the side rail must be required
to treat a medical symptom and there must be a physicians order for the side rail.
If the side rail does not prevent a resident from safely and easily getting out of the
side of the bed at will or does not prevent a resident from involuntarily getting out of
bed, the side rail is not a restraint. This may occur when:
(a) The resident uses the rail for assistance with mobility and can safely and
easily go around the side rail, and the resident does not try climbing over the rail,
(b) The resident uses the rail for assistance with mobility and can easily get out of
the opposite side of the bed by him/herself and does not try climbing over the rail,
(c) The resident can easily lower the side rail and safely get out the side of the bed,
(d) The resident is unable to get out of bed by him/herself and always requires the
assistance of another person. This means the resident is (i) unable to get out of bed
without assistance, (ii) is unlikely to roll out of bed, (iii) is unlikely to be
"thrown" out of bed because of medical or neurological conditions such as
epilepsy or Huntingtons chorea, and (iv) is unlikely to become wedged between the
side rail and the bed.
Generally, a full-length rail will meet the definition of a restraint for a
resident who is otherwise capable of getting out of bed if the resident cannot easily
lower the rail or get out of the opposite side of the bed. A half-rail will generally meet
the definition of a restraint for a resident who is otherwise capable of getting out of
bed if the resident cannot easily lower the rail, cannot get out of the opposite side of
the bed, or cannot easily go around the rail to get out of bed.
What if a resident uses a device that does not meet the
definition of a restraint?
When a resident uses a restraint-like device that can be easily removed or which
does not restrict free movement, staff should assess and care plan its use. Staff also
should make sure that the device does not create a safety hazard for the resident. For
example, if a resident uses a side rail for positioning and can safely and easily get out
the side of the bed, staff should assure that the resident will not get caught between the
rails or between the bed and the rail. Similarly, if a belt is used solely for
positioning, staff should take necessary precautions to make sure the resident cannot
passively slide down in the chair and get the belt caught around his/her neck. Staff need
to monitor the use of these devices and to re-evaluate their safety, particularly as the
residents condition changes.
Can a competent resident request a restraint? Often, a
competent resident will request a restraint. Most often, the resident requests a side rail
because s/he worries about falling out of bed. A residents right to participate in
care planning and to refuse treatment, including the right of the resident to accept or
refuse the use of side rails, must not be denied. Facility staff should:
Assess the resident and the request. Determine why the resident is requesting the
Describe to the resident alternative individualized care practices that may be safer and
appropriate for the resident. Help the resident understand that these alternatives may
help him or her to feel secure. Alternatives might include lowering the bed; placing
cushions or an extra mattress on the floor next to the bed; placing pillows on the open
side of the bed that prevent rolling but not getting out of bed; or getting a different
type of bed. Staff might also check the resident more often and offer interventions such
Talk about the risks involved with the resident. Stress that side rails are not
benign safety devices and their use may pose a significant risk to the resident. In
Wisconsin, in November 1997 alone, there were two resident deaths due to side rails.
If the resident insists that s/he wants a side rail and makes an informed decision, the
facility may use a side rail if it determines that the side rail can be safely used with
the resident. We recommend getting signed consent from the resident and keeping this form
on file. (Some facilities use a consent form that lists all the risks associated with
restraint and/or side rail use.) If the side rail functions as a restraint, its use must
be consistent with physician orders. We expect that staff will work with the resident to
reduce the residents anxiety about falling out of bed. In all cases, staff should
monitor the safety of the rail so the resident does not become wedged between the
bed/mattress and the rail or climb over the rail.
What if a legal representative insists on using a restraint?A
facility should use a team approach to select effective individualized interventions for
each resident. Everyone needs to be included, especially the resident, the legal
representative, and physician. While legal representatives may refuse treatment options in
accordance with their legal authority, they cannot dictate care that is not
medically necessary or safe for the resident. The decision to use a restraint is a
collective decision that rests with the interdisciplinary team. This team determines
whether a physical restraint is required to treat the identified medical symptom. This is
reflected in the guidance to surveyors found at F221 [42 CFR 483.13(a)]. This guideline
states, "The surrogate or representative cannot give permission to use restraints for
the sake of discipline or staff convenience or when the restraint is not necessary to
treat the residents medical symptoms. That is, the facility may not use restraints
in violation of the regulation solely because a surrogate or representative has approved
or requested them." Similarly, the interpretive guideline at F152 [42 CFR
483.10(a)(3)] states, "The involvement of a surrogate or representative does not
automatically relieve a facility of its duty to protect and promote the residents
interests. For example, a surrogate or representative does not have the right to insist
that a treatment be performed that is not medically appropriate..."
When a legal representative disagrees with the decision of the interdisciplinary team
to reduce restraints or not to use a restraint, the facility should:
Listen to the concerns and fears the legal representatives is raising to determine the
underlying reasons for those fears and concerns. The facility, in turn, should convey its
concerns about the significant potential hazards created by using a physical restraint.
(These include a greater tendency to pressure ulcers, incontinence, urinary tract
infection, dehydration, and malnutrition, loss of bone mass, loss of mobility, feeling
like a prisoner, loss of self esteem, injuries from a fall, and death by asphyxiation.)
Several videos are now available to assist in this education process. For example, the
video series "Everyone Wins" is available in each BQA regional office and
through several provider organizations. In addition, the pamphlet, Avoiding Physical
Restraint Use: New Standards in Care, is available for residents and families.
You may obtain a copy by writing or calling the National Citizen's Coalition for Nursing
Home Reform, 1424 - 16th St. NW, Suite #202, Washington, DC 20036; phone 202-332-2275.
Cost is $7.50 + $3.00 for shipping and handling.
Upon hearing the concerns, staff should problem-solve with the legal representative who
objects to restraint reduction. If the concern of a legal representative is that a
resident may fall because the resident is weak, the legal representative may consent to
restraint reduction if the resident first becomes involved in a strengthening program.
Similarly, the legal representative may consent to restraint reduction if staff lower the
bed or gradually phase in the program, beginning with supervised, short periods where the
resident is not restrained. Staff might also invite the legal representative to talk with
residents or the families of residents who have successfully become restraint free despite
their initial misgivings.
Contact the Ombudsman assigned to your facility. Ombudsmen are able to provide
assistance in problem solving and in educating the legal representative about alternatives
to restraint use.
When the wishes of the resident, guardian, or surrogate decision maker conflict with
the recommendations of the interdisciplinary team, BQA expects facilities to attempt to
educate the individual(s) about the dangers of using physical restraints. Staff should
work toward developing an approach to which all parties can agree. This may include
restraint reduction that is phased-in over a reasonable period of time.
The resident or legal representative should understand that the resident may fall and,
depending upon staff evaluation of the fall, that a fall will not necessarily signal the
immediate return to restraints. Being restraint-free does not necessarily mean being
fall-free. However, research has shown that an unrestrained resident is two times less
likely to fall and three times less likely to sustain a serious injury from a fall than a
restrained resident (American Journal of Nursing, May 1992). For any resident who
falls, including those in restraint reduction, staff should evaluate all the circumstances
surrounding each fall. With this information, staff should determine what went wrong and
what measures they should implement to reduce the possibility for further falls and to
keep the resident safe. These measures should then be consistently implemented across all
shifts each day of the week.
If you have any questions concerning restraint use and restraint reduction, please
contact the Regional Field Operations Director or Supervisor
at the phone number listed below [use this link instead].
EXAMPLE OF RESTRAINT ASSESSMENT
1. Resident falls while getting out of bed. Resident is capable of
movement that allows her to get out of bed or a chair but is unable to walk more than 5
feet without assistance.
2. Data collection. Staff determine that the resident is usually
getting out of bed and falling near her bed between 4 and 5:00 a.m. The resident states
that she is getting up because she has to go to the bathroom. She says her bladder must be
getting weak because she never used to have to get up during the night to use the
bathroom. The resident states that she uses her call light but staff are not responding
quickly enough. When she gets to the point where she cannot hold it any longer she gets up
and tries to make it to the bathroom by herself. The resident uses a wheel chair during
the day but does not attempt independent transfer. She says that staff respond quickly to
her requests to go to the bathroom during the day.
3. Assessment. The resident experiences orthostatic hypotension
when getting up from a bed or chair. Her strength and muscle tone are weak. This has been
exacerbated by a recent illness that has left the resident much weaker than usual. Blood
sugar levels are high and may be contributing to nocturia. None of the residents
medications have side effects or interactions that could contribute to the resident
getting up at night. One medication may be contributing to the residents orthostatic
hypotension. The resident does not have any conditions, such as severe osteoporosis, that
could readily lead to a fracture if a fall occurs.
4. Options. Staff contact the physician for a possible change in
the residents medication, which might reduce the residents orthostatic
hypotension. Staff seek physician evaluation of the residents blood sugar levels,
since the onset of nocturia may be symptomatic of diabetes or a urinary tract infection.
Staff seek evaluation by physical therapy for a strengthening program to help resident
regain the strength needed to independently ambulate. Short-term approaches: Bed alarm to
alert staff when the resident tries to get up out of bed. Anticipate residents need
to urinate during the night by waking her at 4:00 a.m. to assist her to the bathroom.
Staff to promptly respond when the resident turns on her call light.
5. Consent. Staff talk with the resident (or legal representative
if the resident has legally been declared not competent). Staff explain options so the
resident (or legal representative) can make an informed decision. Staff obtain consent.
6. Attempt lesser restrictive measures. Implement short-term
approaches and monitor for the effectiveness of reducing the number of falls.
7. Re-evaluate the effectiveness of this plan. Staff modify the
plan as the residents condition changes. Medication changes may reduce the
residents orthostatic hypotension and improvements in the residents strength
and gait may make the resident capable of independent transfer.
FREQUENTLY ASKED QUESTIONS ABOUT PHYSICAL RESTRAINTS
1. Is the ultimate goal of restraint reduction to make sure that every resident in
every nursing home is restraint free?
No. The ultimate goal is to ensure that the only residents who are physically
restrained are those who require a physical restraint to treat their condition and to help
them achieve their highest practicable level of functioning and well being. When
restraints are used, the restraint should be the least restrictive and should be used for
the least amount of time possible. (See Restraint Reduction
2. How do I count physical restraints for purposes of reporting on the HCFA-672
form, Resident Census and Conditions of Residents?
First, you must identify the residents who use a device such as a side rail, a
wedge cushion, a lap buddy, a geri-chair, a reclining chair, or anything else that might
be considered a restraint. Secondly, you must identify what movement each resident is
capable of making. Once you identify these residents you must determine, for each
resident, whether the device restricts the residents free movement or normal access
to his or her body. Then you must evaluate whether the resident can easily remove the
device. If the device restricts movement and the resident cannot easily remove it, the
device is a restraint and you must count the resident as a person who is physically
restrained. If the device does not restrict movement or normal access to ones body,
or if the resident can easily remove the device, it is NOT a restraint and should not be
counted or reported as one. (See "When reporting the
number of residents in restraints" above.)
3. When is a side rail considered a restraint?
A side rail, no matter what the length, is considered a restraint when it cannot be
easily lowered by the resident and:
it prevents a resident who is capable of getting out of bed by him or herself, from
safely and easily getting out the side of the bed (either around a half-rail, or
the side of bed opposite a full-length or a half-rail), or
it keeps a resident in bed who is capable of either rolling out of bed or involuntarily
being "thrown" out of bed because of a medical or neurological condition such as
A side rail, regardless of length, is not a restraint if it does not prevent a resident
from easily getting out of a side of the bed. The latter may occur when the resident can
safely and easily go around the side, when the resident can get out of the opposite side
of the bed, or when the resident cannot get out of bed unless assisted by another person.
(See Restraint Reduction and Side Rails above.)
4. Can a side rail be used if a competent resident requests it?
A side rail, as well as any device that functions as a restraint, may be used if a
competent resident, who has been informed of the risks, presented with alternative
options, and made an informed consent, requests the restraint. We recommend that the
resident give signed consent and that this form be kept in the residents record. If
the side rail functions as a restraint, its use should be consistent with physician
orders. Facility staff should work with the resident to reduce his/her anxiety about
falling out of bed and should make the resident aware of alternative measures they might
implement to prevent injury from a fall. (See "Can a
competent resident request a restraint?" above.)
5. What if a legal representative disagrees with the facilitys assessment that
a restraining device should not be used?
A legal representative has the right to refuse treatment. However, s/he does not have
the right to demand care or treatment that is not indicated by the residents
condition. Consequently, a family member or a legal surrogate cannot have a resident
restrained when there is no medical reason for using a physical restraint.
A facility should work with the family member or legal surrogate by advising him or her
of the risks of restraint use and by collectively developing approaches to which both can
agree. These might include the gradual reduction of restraints while the resident
participates in a strengthening program, or gradual reduction that begins with one-on-one
supervision while the restraint is removed. A facility may also ask the Ombudsman assigned
to their facility for assistance. (See "What if a legal
representative insists on using a restraint?" above.)
6. Is a wedge cushion a restraint if it prevents a resident from ambulating who
would otherwise be capable of getting up and walking? The resident cannot easily remove
Regardless of the type of device, you must ask two questions: (1) Within the context of
the residents capabilities, does the device restrict a residents free movement
or normal access to his/her body? (2) Is it difficult for the resident to remove the
device? If the answer to both questions is "yes," the device is a restraint. In
this case, because the wedge cushion prevents the resident from ambulating and because the
resident cannot easily remove it, the wedge cushion is a restraint. (See "The litmus test" above.)
7. Is the wedge cushion a restraint if the resident cannot get out of the chair and
the cushion prevents the resident from passively sliding (vs. actively working to slide
down) in the chair?
The wedge cushion is not preventing free movement and is not a restraint. If the
wedge cushion prevents a resident from sliding out of the chair and the resident actively
works at trying to slide out of the chair, then the wedge cushion is a restraint. (See
"The litmus test" above.)
8. What is a "medical symptom"?
A medical symptom is the physical and subjective manifestation of a diagnosis or
condition, or a combination of diagnoses and conditions. Effective treatment of a medical
symptom requires staff to:
Identify the underlying condition(s);
Comprehensively assess the underlying condition(s);
Evaluate the effect and impact that other symptoms or conditions may have on the
underlying condition; and
Identify and thoroughly evaluate the various interventions that might be implemented to
treat the medical symptom.
Falls may be a manifestation of an underlying condition. Effective treatment of falls
begins with identifying all the underlying factors and conditions that may be contributing
to the falls. (For example, staff may look for blood pressure changes, balance
disturbance, medication side effects, not meeting the residents needs, lack of
aggressive rehabilitation/restorative care, lack of meaningful activities, failure to
manipulate the residents environment, etc.) (See "One sequence of assessment" above.)
9. The interdisciplinary team comprehensively assesses a resident. The team
considers the pros and cons of using different options to keep a resident safe. It
concludes that a restraint is the best approach for helping a resident attain or maintain
his/her highest practicable level of functioning and well being. The resident and/or legal
representative consents to the use of the restraint and the physician orders it. Why
should the judgment of a surveyor, who has spent much less time with the resident than we
have, be allowed to overrule and cite us for the decision that we made?
Even if a survey team disagrees with the conclusions, the chances of being cited are
greatly reduced if a facility can provide evidence that a comprehensive, systematic
interdisciplinary-team process has occurred and if there are no obvious errors in the
decisions that were made. A surveyor needs to see that the facility has used a logical and
systematic interdisciplinary-team approach to assessing a resident and reaching the
conclusion that a restraint instead of another alternative is required to enable the
resident to reach his/her highest practicable level of functioning. (See one possible
process outlined on pages 3-6.) Staff should document the data and conclusions that were
reached in each step of the process. Thorough documentation aids staff when reassessing a
resident and serves as proof that the process has occurred. The survey team may cite F272
(assessment) and/or F221 (restraints) if the facility cannot provide evidence that it used
a logical, comprehensive, systematic process and the resident is not achieving his/her
highest practicable level of functioning. The survey team may cite F514 (documentation) if
the process and conclusions can be satisfactorily explained to the team but were not fully
10. Bottom line. When can a facility use a physical restraint?
A facility may use a restraint if the interdisciplinary team determines, through a
comprehensive, logical and systematic assessment process, that a physical restraint is the
least restrictive option required to treat a residents medical symptom. Also,
the restraint must enable the resident to achieve his/her highest practicable level of
functioning and well being. Staff may use a side rail if a competent resident requests it
and has been fully informed of risks and alternatives. (However, the resident should not
be requesting a restraint to prevent falls caused by his/her attempts to walk and to care
for basic needs prompted by staff failure to respond timely to call lights or to
residents needs.) Whenever a restraint is used, it is crucial that staff check the
resident frequently to decrease the chance that injury or death from the restraint will
occur. (See "One sequence of assessment"
A device that does not restrict a residents free movement, or which a resident
can easily remove, is not a restraint. However, facility staff should ensure that the
device does not pose a safety threat to the resident who is using the device.
(See "What if a resident uses a device. . ." above.)
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