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Physical Restraints Found Rampant at Marin Convalescent


The California Department of Public Health (DPH) recently issued seven citations against Marin Convalescent & Rehabilitation Hospital in Tiburon for systematically physically restraining its residents. The Department found myriad violations of restraint regulations including:

  • Restraints issued without a physician’s order;
  • No less restrictive alternatives attempted prior to restraints;
  • No documentation or tracking of the goal of restraints;
  • No time limits on the use of restraints; and
  • Restraints that violated the facility’s own policies and procedures.

A nursing assistant who had worked at the facility for 40 years stated that “all of the facility residents, except one, had dementia and wore belts.” The Director of Nursing stated that the facility restrained residents who “were restless, had a previous fell [sic.], or were at risk of falling.” The residents deemed at risk of falling included those in pain, hungry, or “needing to use the restroom.” In other words, every resident “needed” to be restrained.

The facility medical director stated that he “rubber stamped” the recommendations of the staff when they asked to initiate physical restraints. He claimed not to know that the law and good health care practice requires less restrictive measures be attempted before turning to restraints.

In one particularly depressing case, a resident was found to have been restrained to her bed for staff convenience as she laid in a darkened room with a nearly closed door. She was tied down and had all of her bed rails raised. The facility staff also administered a powerful tranquilizing drug to the resident around the clock because - despite the restraints – she “wouldn’t keep still.”

Despite finding the parade of restraint horribles at Marin Convalescent, DPH issued meager Class B citations with $1,000 fines, indicating the residents did not suffer any harm from being illegally tied down and drugged. Perhaps DPH’s investigators need some education on the profound adverse psychological and health consequences of restraints.

Marin Convalescent must be the nursing home that time (and law enforcement) forgot. Reducing physical restraints was a fairly successful campaign of nursing home residents and advocates more than 25 years ago. One wonders how many hundreds or even thousands of residents have suffered the terrible indignity and health dangers of being tied down unnecessarily at Marin Convalescent since then.