Restraint Management

Effective Date: [Original NPP Date]
Revised Date: [Current Date]

Policy

It is the policy of this facility to utilize restraints only when clinically justifiable to treat the resident's medical condition while maintaining the resident’s highest practicable level of physical and psychological well-being. Restraints will be utilized only after alternatives to restraints and/or least restrictive restraints have been attempted. The need for a restraint will be evaluated by the interdisciplinary team (IDT) and this recommendation will be reviewed with the resident and/or responsible party. The IDT will evaluate the resident quarterly to determine the need for continued use of the restraint and to evaluate for opportunities to reduce or eliminate the restraint.

Definition

I. Physical Restraints: Physical restraints are any manual, mechanical, or physical 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 body. Physical Restraints include, but are not limited to, leg restraints, arm restraints, hand mitts, waist ties, or vest, lap cushions, and lap trays the resident cannot remove easily. Also included as restraints are facility practices that meet the definition of a restraint, such as:

• Using side rails that prevent a resident from voluntarily getting out of bed;
• Tucking in, or using Velcro to hold a sheet, fabric, or clothing tightly so that a resident’s movement is restricted;
• Using devices in conjunction with a chair, such as trays, tables, bars, or belts, that the resident cannot remove easily, that prevent the resident from rising;
• Placing a resident in a chair (e.g. recliners, Geri-chairs) that prevents a resident from rising;
• Placing a chair or bed so close to a wall that the wall prevents the resident from rising out of the chair or voluntarily getting out of bed.

II. Chemical Restraint: Any drug that is used for discipline or convenience and not required to treat medical symptoms. This facility does not promote the use of chemical restraints.

III. Risk of Entrapment: Physical Restraints can create a risk for entrapment and injury to the resident. This risk needs to be evaluated and reviewed by the IDT to decrease the resident’s risk of injury from entrapment.

Practice Guidelines

I. When a resident’s condition indicates that an intervention is necessary for safety or positioning, all alternatives to restraints will be tried first and documented in the Nurses Notes and/or in the care plan. These alternatives are discussed by the IDT.

II. When all appropriate alternatives outlined in the care plan are unsuccessful, the Restraint Evaluation will be completed by the IDT, prior to initiating the use of a restraint.

III. If a restraint is indicated, the least restrictive alternative will be tried unless there is a clinical indication for a more restrictive device.

IV. The resident, family member, or legal representative will be notified and educated on:

• How the use of the restraint will treat the resident’s medical symptoms and assist in attaining the highest practicable level of physical and psychological well-being.
• The potential negative outcomes of the restraint usage (e.g., loss of dignity, loss of independence, withdrawal, depression, incontinence, constipation, pressure sores, decrease in ambulatory abilities, and/or death).
• Alternatives to restraint use.

V. If the resident, family member, or legal representative agrees to the use of the restraint, written authorization (Physical Restraint Consent) is placed in the Clinical Record and the device is then implemented for the specified time frame. A verbal consent may be obtained until a written consent is available.

Note: If a resident is incapable of making decisions, the surrogate or representative will exercise the right to refuse or accept the use of restraints but may not give authorization for a restraint when not necessary to treat the resident’s medical condition.

VI. A physician’s order for the use of the restraint is obtained.

VII. When a restraint is initiated, there will be documentation in the medical record q shift x 72 hours documenting the resident’s response, both physical and psychological, to the restraint.

VIII. The clinical indication that would warrant the use of restraints is reflected in the Restraint Evaluation and care plan.

IX. A “Restraint Review” is done at least quarterly to determine the continued need for the restraint device and to continually evaluate for opportunities to reduce or eliminate the restraint. This is done by the IDT at the quarterly care plan meeting.

X. Whenever a resident is admitted with orders for a restraint, the staff may accept the order for up to 72 hours pending completion of the Restraint Evaluation provided:

• The licensed nurse has consulted with the physician and documented resident history and appropriateness of restraint in the Nursing Notes.
• The least-restrictive device is used during the evaluation period.
• Resident/family/legal representative consent is received and documented.
• The reason for restraint usage is documented on the care plan.

Note: Do not accept a Restraint Order simply because it is on the W-10.

XI. All restraints will have a specific physician order to include:

• Type of device
• Medical symptom
• How often the device is to be used and duration of use
• Frequency of checking and removing (minimum of every two (2) hours).

Note: No restraint may be applied (except during an emergency) unless there is a specific physician order.

XII. Follow manufacturer’s recommendations for use of the restraint device.

XIII. If the IDT decides restraint reduction is appropriate and the responsible party does not agree:

• The facility social worker/DNS will explain the risks/benefits of restraint reduction and educate the family on alternatives that will be used and safety interventions.
• If an agreement cannot be reached, a letter will be sent from the facility social worker explaining the policies and procedures of restraint usage based on Federal Regulations.
• If the responsible party will not meet on the above, the Administrator, Director of Nurses, or delegate will contact the primary physician to notify him/her of the responsible party’s reason for refusal to reduce restraints. A meeting will be set up between the responsible party, the Medical Director (if available), Administrator, and the IDT to determine the least restrictive intervention, if any, for the individual.
• If a decision to reduce a restraint cannot be reached by the responsible party, the case will then be presented to the state’s ombudsman.
• If a decision to reduce a restraint still cannot be reached, the facility is bound to seek alternative measures. A restraint cannot be applied simply as a request by a responsible party.

Restraint Evaluation

Resident Name: ___________________________________________

Date: __________________________________

Rationale for the use of a restraint as determined by the IDT:

Alternatives to restraints that have been utilized:

• Diversional Activities
• 1:1
• Re-Orientation
• Safety Education
• PT Screen
• Alarms for Trending Behavior
• Review of Environment
• Positioning Devices
• Other

Least restrictive restraints attempted:

• Velcro Seat Belt _____
• Clip Seat Belt_____
• Alarmed Seat Belt_____
• Lap Buddy_____
• Tray Table_____

If the least restrictive restraint option is not being utilized first, explain rationale:

Restraint utilization reviewed with resident and/or responsible party?

_____Yes _____No

Date: _________________________________

Name:___________________________ Name:__________________________ Responsible Party Staff

Resident/responsible party gives consent to utilize restraint?

_____Yes _____No

Signature: ________________________________________

Resident/Responsible Party Consent/Refusal to Utilize Restraints

The following information has been reviewed with me:

• Alternatives that have been tried prior to the recommendation for a restraint.
• Least restrictive restraints that may have been tried.
• Rationale for the utilization of the restraint.
• Risks associated with the use of a restraint including:
  • Loss of dignity
  • Loss of independence
  • Withdrawal
  • Depression
  • Incontinence
  • Constipation
  • Pressure sores
  • Decrease in ambulatory abilities
  • Injury from entrapment
  • Death

Name of Resident: ______________________________________________

I agree to the use of a restraint _____________

I do not agree to the use of a restraint ____________

Date: _________________________________

Resident Signature: ______________________________________________

Responsible Party Signature (if applicable) ___________________________________

Facility Representative Signature: __________________________________________

Restraints Least to Most Restrictive

Bed Positioning I. Quarter Siderails Down II. One Quarter Siderail Up III. Two Quarter Siderails Up

Chair Position I. W/C with Velcro Seat Belt II. W/C with Wedge Cushion III. W/C with Clip Seat Belt IV. W/C with Lap Buddy V. W/C with Lap Tray VI. G/C Recliner

Standing Position/Ambulation I. Merri Walker

References:

• Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities. [Link to current CMS SOM]
• CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]