Should we tie a patient down in bed to prevent a fall? March 13, 2009

Many of our clients have told us that when their elderly loved ones are in a hospital, nurses used wrist restraints and bedside rails to keep them from falling out of bed. Then after the hospital at a nursing home, the nurses claim that side rails cannot be used because they are “restraint’ and they are against the law. Since we hear this from our clients it is usually because the side rails were not used and the patient fell out of bed and broke a bone.

The fact that bedside rails are considered a restraint is normally a surprise to our clients. In fact anything that interferes with a patient’s freedom of movement is a restraint and is subject to legal regulation. This is morally correct because as a culture we have decided we want to respect other’s independence even if they are elderly and in a nursing home. Our federal government and state legislatures have passed laws giving nursing home patients rights to be free and Independent. However, many of the people in nursing homes suffer from dementia or have some other mental difficulty which keeps them from understanding their situation.

In these circumstances, a spouse or child often ends up having to make decisions about how to best provide quality care to ensure a patient’s safety. The problem with medical care is that every medical intervention has risks associated with it. For instance if we decide to use a seatbelt to keep an elderly patient from getting out of a wheelchair because the patient is very unsteady on her feet and we are afraid she will fall and break a hip, we limit the patient’s independence and may interfere with her chances of recovering the ability to walk with a steady gait. On the other hand if we do not use the seatbelt and the patient gets out of the wheelchair, falls and breaks a hip, the patient may experience excruciating pain, will likely have to undergo an operation to repair the hip and the risks of other medical complications and an earlier death go up.

Even bedside rails have some risks. Patients have been injured being caught between the mattress and the bedside rails. And the bedside rails interfere with the patient’s freedom of movement in a way that is mentally distressing to the patient. For example what if the patient wants to get up to go to the bathroom, a nurse is not readily available to respond to a call bell and the patient cannot get out of bed because of the side rails?

Although there are no easy answers to these kinds of questions which arise all the time in hospitals and nursing homes we are most likely to get to the best result if family members, the doctor, nurses and other health care providers involved all work together to make the best decision. Federal regulations are in place to protect the patient and also to be sure that health care providers carefully think through decisions about restraint use.

Despite what anyone may tell you to the contrary, restraints are, in fact, allowed under the law applicable to nursing homes and they may have a place for a particular patient. The challenge, however, is to carefully think through the decision about restraint use or non-use for each individual resident to get to the best decision.

The federal regulation for nursing homes provides that, “the resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.” Therefore, restraints are allowed when required to treat the resident’s medical symptoms and are not for the purpose of discipline or convenience.

The State Operations Manual which provides guidance to nursing homes also makes it clear that restraints are allowed under appropriate circumstances. “Medical symptom” is defined as an indication or characteristic of a physical or psychological condition. The manual explains that, “the resident’s medical symptoms should not be viewed in isolation, rather the symptoms should be viewed in the context of the resident’s condition, circumstances, and environment.” The manual also explains that a physician’s order alone is not sufficient to warrant the use of a restraint and that there should be some type of process for gradual reduction of the use of restraint if appropriate. A legal surrogate or representative cannot give permission to use restraints for discipline or convenience and the facility may not use restraints in violation of the regulation solely based on a surrogate’s request or approval.

The Operations Manual contains a checklist of questions that are helpful in describing the type of thorough thought process that should be completed when deciding on restraint use or non-use. Paraphrased, they are as follows:

1) What are the medical symptoms that lead to the consideration of the use of restraints?

2) Are the symptoms caused by failure to meet the resident’s needs, provide rehabilitation / restorative care, provide meaningful activities, or manipulate the resident’s environment?

3) Can the medical symptoms be eliminated or reduced?

4) Have alternatives to restraints been attempted?

5) Does the facility use the least restrictive restraint for the least amount of time while adequately monitoring restraint use for the resident?

6) Did the resident or legal surrogate give informed consent after explanation of risks, benefits and alternatives?

7) Does the facility use the physical restraints protocol to evaluate the appropriateness of restraint use and has the facility re-evaluated the need for restraints?

Family members with loved ones in Volusia County, Daytona Beach, Ormond Beach and Florida nursing homes serve the interests of their loved ones if they have this information and insist that the nurses and doctors carefully think through these questions before making any decisions about the use of restraints. Restraints do have a place in the list of medical care options, but they should be carefully considered before being used.