Restraint - What Does That Mean in a Nursing Home Setting?

RESTRAINT - What does that mean in a Nursing Home Setting?
By: Lauren Ellerman
If you look up restraint in the dictionary, you may see one of these definitions: (1) the act of restraining, holding back, controlling or checking; (2) the state or fact of being restrained; deprived of liberty; confinement.
But what does the term "restraint" mean in a nursing home or hospital setting? You may be researching facilities and learn that one has a restraint free policy. The Virginia Administrative Code Section that speaks to Nursing Home facilities defines a "Physical restraint" as "any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's own body." 12 VAC 371-10. The same section defines a "Chemical restraint" as "a psychopharmacologic drug (a drug prescribed to control mood, mental status, or behavior) that is used for discipline or convenience and not required to treat medical symptoms or symptoms from mental illness or mental retardation that prohibit an individual from reaching his highest level of functioning." 12 VAC 371-10.
Although these are more technical definitions, they mean the same thing - either something tangible or a medication that restricts the movement or level of function of an individual. So why would you want to restrict the level of function or movement of someone?
Imagine an Alzheimer's patient that has poor awareness of her surroundings. Would a device that prevented her from leaving the nursing home be helpful? Or, consider someone who becomes aggressive toward others due to dementia - wouldn't a psychopharmacologic drug that helps control that behavior be appropriate? The answer as to whether or not these physical or chemical restraints should be used is neither simple, nor clear. Families and friends of nursing home residents need to educate themselves on the use of restraints, their pros and cons, and make decisions regarding their use accordingly.
For starters, what are examples of physical restraints?

• Bed rails


• Wheel-chair straps / seat belts / lap buddies


• Meri-walker


• Walker with wheels


• Door restraints

Why would a facility consider using any of these with your loved one? Maybe to prevent falls, which is always a goal, but other consequences can be equally devastating. Hundreds of people every year get caught in bedrails and suffer injury, strangulation, and frequently death. Keeping someone in bed or limiting their ability to get out of bed may also put the individual at risk of developing pressure ulcers or bed sores and incontinence. Additionally, there are mental and psychological effects that occur when you limit someone's freedom and take away simple choices, such as when to get out of bed.
Meri-walkers may provide some stability for an ambulating resident but accidents frequently happen when residents in meri-walkers are faced with stairs, changes in the floor grade etc. Not only will the momentum of the walker help cause a fall, but the device itself may become entangled on the person and cause greater injury.
Wheel chair straps may prevent someone from getting out of the chair, but again, what if they come to a stairwell and have no means of stopping, getting up or preventing the fall. The injury could be fatal.
Chemical restraints can be equally dangerous. If a resident is given too much medication, they may have decreased appetite and suffer dehydration or malnutrition. They may also be less mobile, and at risk for pressure ulcers. If they are mobile, many medications may cause focus and balance problems, leading to increased fall risk. The risks are many and must be considered by the prescribing physician to evaluate dose, frequency etc.
Unfortunately, thousands of families have dealt with accidents, injuries and deaths caused, in whole or in part, by the use of physical and chemical restraints in medical care settings. Our office has handled cases involving each of the above restraints scenarios. Unfortunately, injury involving restraints are not uncommon. The lesson we take from these experiences is that restraints should only be used when absolutely necessary, and only if families have had the opportunity to speak to a physician about the known risks and benefits. So while they may sound like a great idea at first, please do your homework and ask the facility the following:
- How many other residents use this restraint?
- Will it make my father more mobile or less? Will you monitor him accordingly?
- What will you do to make sure he does not get caught in the bed rails or wheelchair strap?
- Will you review the use of the restraint monthly - if so, may I attend?
If the facility will not provide any additional monitoring because of the restraint, then its use should be very limited. At the very least, make sure the physician and facility are on the same page, and understand your concerns.