Restraint-Free Care

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Years ago, there was a common misconception that restraints improve the safety of frail elders. The truth, however, is that restraints are dangerous and often cause harm to nursing home residents. Many studies document the dangers and recommend more humane methods to improve the safety of nursing home residents.

Reflecting this understanding, nursing home residents today have strong rights to be free from inappropriate use of restraints under federal and California laws. In most cases, nursing home use of restraints is a form of neglect or abuse.

This fact sheet is about protections against misuse of physical restraints in nursing homes. CANHR publishes a separate guide on nursing home residents’ right to be free from chemical restraints, Toxic Medicine: What You Should Know to Fight the Misuse of Psychoactive Drugs in California Nursing Homes.

What is a Physical Restraint?

A physical restraint is a device, item or practice that restricts a resident’s freedom of movement.

Federal guidelines define “physical restraint” as any manual method, physical or mechanical device, equipment or material that meets the following criteria:

  • Is attached or adjacent to the resident’s body;
  • Cannot be removed easily by the resident; and
  • Restricts the resident’s freedom of movement or normal access to his or her body. Centers for Medicare & Medicaid Services (CMS) State Operations Manual (SOM) Appendix PP at F604.

Some examples of physical restraints are vests, leg and arm restraints, hand mitts, and soft ties.

The way an item is used determines if it is considered a physical restraint. Belts, trays, tables, and bars found on some chairs are considered restraints if they are used to restrict residents’ movement and residents cannot easily remove them. SOM Appendix PP at F604.

Other methods of restraint include moving a chair or bed against a wall so residents cannot get out or tucking in a bed sheet so tightly that residents cannot move. SOM Appendix PP at F604.

As discussed below, bedrails might also be considered a physical restraint, depending on how they are used. SOM Appendix PP at F604.

Position change alarms – which are monitoring devices that signal when a resident moves – are considered restraints when residents avoid moving out of fear of setting off alarms. SOM Appendix PP at F604.

What Risks Are Caused by Physical Restraints?

Physical restraints are inherently dangerous and especially so when used to confine frail individuals with cognitive impairments. Many residents have been seriously injured while trying to escape restraints or been harmed by inappropriately applied restraints. Restraints often cause incontinence, poor circulation, weak muscles, chronic constipation, pressure sores, depressed appetite, loss of mobility and increased illness. They also diminish independence and social contact, often leading to withdrawal, loneliness, depression, anxiety and agitation.

What Are the Rights to Be Free from Misuse of Physical Restraints?

Residents have the right to be free from involuntary seclusion and any physical restraint not required to treat the resident’s medical symptoms. Nursing homes must ensure that residents are free from physical restraints imposed for purposes of discipline or convenience. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. 42 CFR §483.12, 42 CFR §483.10(e)(1), 42 USC §1396r(c)(1)(A)(ii), 22 CCR §72527(a)(24).

Most importantly, nursing home residents cannot be restrained without their informed consent. Before restraints can be used, the resident’s physician must disclose, at a minimum, the following information: (1) the reason for the restraint and why it is recommended; (2) the medical condition for which the restraint is needed; (3) the type of restraint that is recommended; (4) how long and how often the restraint will be used; (5) how the relevant medical condition will be affected; (6) the nature, degree, duration and probability of known side effects; (7) the reasonable alternatives; and (8) the right to accept or refuse care and treatment. 22 CCR §72528.

Informed consent for use of a physical restraint must be obtained in advance except for emergency situations. 22 CCR §72528.

Residents have the right to refuse consent for physical restraints. A resident who has given consent for use of physical restraints has the right to revoke consent for any reason at any time. 22 CCR §72528.

A nursing home cannot use a physical restraint when it is not medically necessary even if a resident or legal representative request it to do so. SOM Appendix PP at F604.

Are Bedrails Considered a Physical Restraint?

Often, yes. Federal standards on bedrails restrict but do not completely forbid their use in nursing homes and set strict safety protocols. Many residents have died or suffered serious injuries from entrapment in bedrails, leading CMS to strengthen its standards about their use. 42 CFR §483.25(n), 42 CFR §483.90(d)(3), SOM Appendix PP at F604 & F700.

A bedrail is considered to be a restraint if the bedrail keeps a resident from voluntarily getting out of bed in a safe manner due to physical or cognitive inability to lower the bedrail independently. SOM Appendix PP at F604.

Bedrails may have the effect of restraining one individual but not another, depending on a resident’s conditions and circumstances. For example, the use of partial bedrails may assist an independent resident to enter and exit the bed independently and would not be considered a physical restraint. SOM Appendix PP at F604.

For more detailed information on federal nursing home standards on use of bedrails, see CANHR’s guide on Nursing Home Care Standards.

Alternatives to Physical Restraints

There are many alternatives to physical restraints. Some enhance safety and comfort for all residents, such as increasing staffing levels to improve supervision, removing accident hazards, providing safe areas for residents to walk, and training staff how to identify and respond to unmet needs. Others address individual resident needs and preferences, such as adapting and tailoring chairs to ensure comfort and safety, using pads and pillows to support comfortable and safe body positions, providing therapy and restorative care to improve a resident’s abilities to move safely, adjusting care and caregiver assignments to a resident’s preferences, and using low beds and floor padding to safeguard against harmful falls from bed.

Advocacy Tips

  • Don’t be afraid to say “No” if the nursing home proposes to use physical restraints. It is not only possible for a nursing home to avoid using physical restraints, it is common. Many nursing homes do not use physical restraints at all. Nationally, nursing homes report that they physically restrain less than one percent of residents. Tell the nursing home you know better than to allow restraint.
  • Request alternative methods of care or treatment. Refusing restraints does not change a nursing home’s responsibility to keep you safe.
  • Ask for a care conference to discuss options if a nursing home proposes using a physical restraint. Doing so provides an opportunity to discuss alternatives and to update your care plan to reflect your choices. Although nursing homes often go through the motions with care conferences, you have strong rights to make the conference center on your goals. Learn about care planning rights in CANHR’s fact sheet, Making Care Plans Work.