CMS	Centers for Medicare & Medicaid Services
FDA	Food and Drug Administration
OBRA	Omnibus Budget Reconciliation Act of 1987
ROM	Range-of-motion
TJC	The Joint Commission

Chapters 13 and 14 have many safety measures. However, some persons need extra protection. They may present dangers to themselves or others (including staff).

The Centers for Medicare & Medicaid Services (CMS) has rules for using restraints. Like the Omnibus Budget Reconciliation Act of 1987 (OBRA), CMS rules protect the person’s rights and safety. This includes the right to be free from restraint. 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. They must be discontinued as soon as possible.

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.

• Convenience—any action taken to control or manage a person’s behavior that requires less effort by the staff; the action is not in the person’s best interest.

• Discipline—any action taken by the agency to punish or penalize a patient or resident.

• Remove easily—the manual method, device, material, or equipment used to restrain the person that can be removed intentionally by the person in the same manner it was applied by the staff. For example, the person can put bed rails down, untie a knot, or unclasp a buckle.

History of Restraint Use

Restraints were once used to prevent falls. Research shows that restraints cause falls. Falls occur when persons try to get free of the restraints. Injuries are more serious from falls in restrained persons than in those not restrained.

Restraints also were used to prevent wandering or interfering with treatment. They were often used for confusion, poor judgment, or behavior problems. Older persons were restrained more often than younger persons were. Restraints were viewed as necessary devices to protect a person. However, they can cause serious harm, even death. See “Risks From Restraint Use” on p. 203.

Besides the CMS, the Food and Drug Administration (FDA), state agencies, and The Joint Commission (TJC—an accrediting agency) have guidelines for restraint use. They do not forbid restraint use. They require considering or trying all other appropriate alternatives first.

Every agency has policies and procedures for restraints. They include identifying persons at risk for harm, harmful behaviors, restraint alternatives, and proper restraint use. Staff training is required.

Restraint Alternatives

Often there are causes and reasons for harmful behaviors. Knowing and treating the cause can prevent restraint use. This is very important for persons with speech or cognitive problems. The nurse tries to find out what the behavior means.

Restraint alternatives for the person are identified in the care plan (Box 15-1). The care plan is changed as needed. Restraint alternatives may not protect the person. The doctor may need to order restraints.

Box 15-1

Restraint Alternatives

Physical Needs

• Life-long habits and routines are in the care plan. For example, showers before breakfast; reads in the bathroom; walks outside before lunch; watches TV after lunch.

• Pillows, wedge cushions, and posture and positioning devices are used.

• Food, fluid, hygiene, and elimination needs are met.

• The bedpan, urinal, or commode is within the person’s reach.

• Back massages are given.

• A calm, quiet setting is provided.

• Exercise programs are provided.

• Outdoor time is planned for nice weather.

• Furniture meets the person’s needs (lower bed, reclining chair, rocking chair).

• Observations and visits are made at least every 15 minutes. Or as often as directed by the nurse and the care plan.

• The person is moved to a room close to the nurses’ station.

• Light is adjusted to meet the person’s needs and preferences.

• Staff assignments are consistent.

• Sleep is not interrupted.

• Noise levels are reduced.

Safety and Security Needs

• The call light is within reach.

• Call lights are answered promptly.

• The person wanders in safe areas.

• All staff are aware of persons tending to wander. This includes staff in housekeeping, maintenance, the business office, dietary, and so on.

• Knob guards are used on doors.

• Falls and injuries from falls are prevented (Chapter 14).

• Padded hip protectors are worn under clothing (Fig. 15-1, p. 202).

FIGURE 15-1 Hip protector. (Image courtesy Posey Company, Arcadia, Calif.)

• Floor cushions are placed next to beds (Chapter 14).

• Roll guards are attached to the bed frame (Fig. 15-2, p. 202).

FIGURE 15-2 Roll guard. (Image courtesy Posey Company, Arcadia, Calif.)

• Warning alarms are used on beds, chairs, and doors.

• Walls and furniture corners are padded.

• Procedures and care measures are explained.

• Frequent explanations are given about equipment or devices.

• Confused persons are oriented to person, time, and place. Calendars and clocks are provided. See Chapter 49.

Love, Belonging, and Self-Esteem Needs

• Diversion is provided—TV, videos, music, games, relaxation, and so on.

• Family and friends make videos of themselves for the person to watch.

• Videos are made of visits with family and friends for the person to watch.

• Time is spent in supervised areas (dining room, lounge, by the nurses’ station).

• Family, friends, and volunteers visit.

• The person has companions or sitters.

• Time is spent with the person.

• Extra time is spent with a person who is restless.

• Reminiscing is done with the person.

• The person does jobs or tasks he or she consents to.

Safe Restraint Use

Restraints can cause serious injury and even death. CMS, OBRA, FDA, and TJC rules and guidelines are followed. So are state laws. They are part of the agency’s policies and procedures for restraint use.

Restraints are not used to discipline a person. They are not used for staff convenience. Restraints are used only when necessary to treat medical symptoms. A medical symptom is an indication or characteristic of a physical or psychological condition. Symptoms may relate to physical, emotional, or behavioral problems. Sometimes restraints are needed to protect the person or others. That is, a person may have violent or aggressive behaviors that are harmful to self or others or that are threatening to others.

See Focus on Surveys: Safe Restraint Use.

Focus on Surveys

Safe Restraint Use

Agencies must have a policy about restraint use. Surveyors will try to learn if restraints were used:

• For discipline or staff convenience

• Only for a certain time for the person’s well-being

Surveyors will review medical records and interview staff. Some questions will focus on:

• How staff members define “restraint.”

• The medical symptoms leading to restraint use. Could they be reversed or reduced?

• The cause of the medical symptoms. Were they caused by failure to:

• Meet the person’s needs

• Provide rehabilitation

• Provide meaningful activities

• Change the person’s setting for safety

• If restraint alternatives were used.

• If the least restrictive restraints were used.

• If restraints were used for a short time.

Physical and Chemical Restraints

According to the CMS, a physical restraint includes 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 removed easily by the person.

• Restricts freedom of movement or normal access to one’s body.

Physical restraints are applied to the chest, waist, elbows, wrists, hands, or ankles. They confine the person to a bed or chair. Or they prevent movement of a body part. Some furniture or barriers also prevent freedom of movement.

• A device used with a chair that the person cannot remove easily. The device prevents the person from rising. Trays, tables, bars, and belts are examples (Fig. 15-3).

FIGURE 15-3 This lap-top tray is a restraint alternative. It is a restraint when used to prevent freedom of movement. (Image courtesy Posey Company, Arcadia, Calif.)

• Any chair that prevents the person from rising.

• Any bed or chair placed so close to the wall that the person cannot get out of the bed or chair.

• Bed rails (Chapter 14) that prevent the person from getting out of bed. For example, 4 half-length bed rails are raised. They are restraints if the person cannot lower them.

• Tucking in or using Velcro (or other device) to hold a sheet, fabric, or clothing so tightly that freedom of movement is restricted.

Drugs or drug dosages are chemical restraints if they:

• Control behavior or restrict movement.

• Are not standard treatment for the person’s condition.

Drugs cannot be used for discipline or staff convenience. They cannot be used if they affect physical or mental function.

Sometimes drugs can help persons who are confused or disoriented. They may be anxious, agitated, or aggressive. The doctor may order drugs to control these behaviors. The drugs should not make the person sleepy and unable to function at his or her highest level.

Enablers.

An enabler is a device that limits freedom of movement but is used to promote independence, comfort, or safety. Some devices can be restraints or enablers. When the person can easily remove the device and it helps the person function, it is an enabler. For example:

• A chair or wheelchair with a lap-top tray for meals, writing, and so on (see Fig. 15-3). The chair is an enabler. If used to limit freedom of movement, the chair is a restraint.

• A person chooses to have raised bed rails. The bed rails are used to move in bed and to prevent falling out of bed. The bed rails are enablers, not restraints.

Risks From Restraint Use

Box 15-2 lists the risks from restraints. Injuries can occur as the person tries to get free of the restraint. Injuries also occur from using the wrong restraint, applying it wrong, or keeping it on too long. Cuts, bruises, and fractures are common. The most serious risk is death from strangulation.

Box 15-2

Risks From Restraint Use

• Constipation

• Contractures

• Cuts and bruises

• Decline in physical function (ability to walk, muscle problems)

• Infections: pneumonia and urinary tract

• Nerve injuries

• Pressure ulcers

• Social and mental health problems: agitation, anger, delirium, depression, loss of dignity, embarrassment and humiliation, mistrust, loss of self-respect, reduced social contact, withdrawal

• Strangulation

Restraints are medical devices. The Safe Medical Devices Act applies if a restraint causes illness, injury, or death. Also, 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. This is done if the restraint may have contributed directly or indirectly to the person’s death.

Laws, Rules, and Guidelines

Laws (federal and state) and rules (CMS, FDA) for restraint use are followed. So are accrediting agency (TJC) guidelines. Remember:

• Restraints must protect the person. They are not used for staff convenience or to discipline a person. Using restraints is not easier than properly supervising and observing the person. A restrained person requires more staff time for care, supervision, and observation. 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.

• A doctor’s order is required. OBRA, CMS, state laws, FDA warnings, TJC, and other accrediting agencies protect persons from unnecessary restraints. If restraints are needed for medical reasons, 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. This information is on the care plan and your assignment sheet. In an emergency, the nurse can decide to apply restraints before getting a doctor’s order.

• The least restrictive method is used. It allows the greatest amount of movement or body access possible. Some restraints attach to the person’s body and to a fixed (non-movable) object. They restrict freedom of movement or body access. Vest, jacket, ankle, wrist, hand, and some belt restraints are examples. Other restraints are near but not directly attached to the person’s body (bed rails or wedge cushions). They do not totally restrict freedom of movement and are less restrictive. They allow access to certain body parts.

• Restraints are used only after other measures fail to protect the person (see Box 15-1). Some people can harm themselves or others. The care plan must include measures to protect the person and prevent harm to others. Many fall prevention measures are restraint alternatives (Chapter 14).

• Unnecessary restraint is false imprisonment (Chapter 5). You must clearly understand the reason for the restraint and its risks. If not, politely ask about its use. If you apply an unneeded restraint, you could face false imprisonment charges.