Restraint-Free Care

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Years ago, there was a common misconception that restraints improve the safety of frail elders and disabled adults. The truth, however, is that restraints are dangerous and often entail more risks than benefits. Many studies document the dangers and recommend more dignified methods to improve residents’ safety.

Reflecting this understanding, current nursing home laws prohibit the unnecessary use of restraints. Except in an emergency, a nursing home cannot use restraints without the resident’s consent. Residents have the right to be free from any restraint imposed for discipline or convenience or that was unnecessary. A restraint may only be used if the resident’s doctor has ordered it to treat medical symptoms, no other alternatives are available, and only if the restraint will help you function at your highest level.
Despite strong California and federal protections against restraint use, far too many California nursing home residents suffer from unlawful restraint.  California nursing homes use physical restraints at a rate about fifty percent higher than the rest of the nation.  Many more residents are chemically restrained. I

What is a Restraint?

There are two types of restraints, physical and chemical.

Physical restraints are items or practices used to restrict a person’s movement. They include leg and arm restraints, hand mitts, vests, soft ties, or anything else that prevents you from moving around. The way an item is used determines if it is considered a physical restraint. Trays, ‘ tables, bars and belts found on some chairs are considered restraints if they are used to restrict residents’ movement and residents cannot easily remove them. Other methods of restraint include moving a wheelchair against a wall so residents cannot move, using a bedrail to prevent residents from getting out of bed, or tucking in a bed sheet so tightly that residents cannot move. Postural supports, methods to simply improve body position and balance, are generally not considered physical restraints.

Chemical restraints are drugs used to control a person’s behaviors or to sedate or subdue I a person. Psychoactive drugs, which affect emotions or behavior, are often used for this purpose. These drugs are not considered chemical restraints when used to treat diagnosed depression or schizophrenia. Psychoactive drugs are often mis-used on residents who have dementia to control behavior that is simply their way of expressing discomfort, distress, or unmet needs.

CANHR has a special website devoted to stopping the misuse of chemical restraints and a consumer guide on this subject, Toxic Medicine: What You Should Know to Fight the Misuse of Psychoactive Drugs in California Nursing Homes.

Risks Caused by Restraints

Physical restraints are most often used to prevent someone from falling out of a bed or a chair or from walking. Although restraints may prevent some falls and accidents, they cause significant risks. Many residents have been seriously injured while trying to escape restraints or by improperly applied restraints. For example, many people have died from strangulation or been seriously injured when they became trapped or entangled in bedrails.

Other common problems from physical restraints are incontinence, increased agitation, poor circulation, weak muscles, chronic constipation, pressure sores, depressed appetite, loss of mobility and increased illness. Restraints also diminish independence and social contact, often leading to withdrawal, depression, anxiety and agitation.

Even when used properly, psychoactive drugs have numerous potentially dangerous effects. The dangers multiply quickly when these drugs are used as chemical restraints. Although risks vary by drug, common effects are agitation, sedation, disordered thinking, decreased appetite, constipation, low blood pressure and muscle disorders. The extreme sedation associated with psychoactive drugs also leads to the same negative effects caused by physical restraints.

Alternatives to Restraints

A nursing home has many options to help improve resident safety without resorting to restraints:

Methods to Improve a Resident’s Safety

  • Using pads and pillows to support comfortable and safe body positions;
  • Adapting and tailoring chairs to ensure comfort and safety;
  • For wheelchair use, ensuring that it is the correct size, comfortable and in good condition;
  • Responding quickly to physical needs such as hunger, thirst, sleeping, toileting and exercise;
  • Tailoring care and caregiver assignments to residents’ preferences;
  • Providing therapy and restorative care to improve residents’ abilities to stand, transfer and walk safely;
  • Helping residents get in and out of bed as often as needed and desired.

Methods to Improve Safety of All Residents

  • Increasing staffing levels to improve supervision;
  • Adapting the environment through good lighting, safe beds, alarms, and other features;
  • Removing accident hazards, such as over-bed tables with wheels and cluttered dining rooms;
  • Providing safe areas for residents to walk;
  • Training staff on methods to calm residents who are anxious or agitated and to identify and address unmet needs;
  • Arranging mental health treatment for residents who need it.

A variety of strategies may be needed to improve resident care and avoid the use of restraints. The nursing home must carefully assess your health and safety needs and consult with you and your representative about treatment options. Every appropriate option should be tried before restraints are considered.

Many nursing homes use alarms triggered by resident movement in lieu of restraints but alarms cause other problems. A nursing home with alarms blaring is not conducive to rehabilitation or a high quality of life. Alarms reduce resident dignity and perhaps even more importantly, discourage residents from moving when they have an unmet need. Many residents are unable to express their needs verbally so standing or moving may be their only way to inform the nursing home staff that they need to use the bathroom, are hungry, or simply need to move. In addition, alarms often prove ineffective in preventing resident falls because staff members can become less pro-active or grow immune to the alarms because they are activated so often.

Nursing homes must establish an individualized care plan for each resident that spells out care needs and how they will be met. For more information on care plans and your right to help shape yours, see CANHR’s Fact Sheet, Making Care Plans Work.

Right to Accept or Refuse Restraints

Residents have the right to accept or refuse any type of care or treatment, including restraints. Before restraints can be used, the resident’s doctor 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.

A doctor’s recommendation to use restraints, like any treatment option, can be rejected. Except in an emergency, the nursing home cannot use restraints without legal and informed consent. The resident can request the doctor and nursing home use alternative methods of treatment. The following questions can be asked of the doctor or nursing home:

  • What symptom prompted the need for a restraint?
  • Has the cause of the symptom been identified?
  • What efforts have been made to treat or eliminate the cause?
  • Can the medical problem be treated without using a restraint?
  • What alternatives have been considered and tried? Are other options still available?
  • What are the risks and side-effects of using the restraint?
  • What are the nursing home’s policies on using restraints?

If the resident is capable of granting or withholding consent, only the resident may do so. For residents who lack the capacity to make their health care decisions, their legal representative may refuse restraints. Legal representatives generally may not consent to the use of restraints unless the resident has been court-adjudicated incapacitated and the representative is given specific authority to authorize restraints. A resident and legal representative can withdraw consent to use a restraint at any time. A nursing home cannot use a restraint when it is not medically necessary even if a resident or legal representative requests it to do so.

Under California law, persons who may act as your representative include a conservator, an agent designated under a valid power of attorney for health care and your next of kin.

Protecting Your Rights

If your rights are being violated, contact your local ombudsman office or CANHR for information on actions you can take. You have the right to file a complaint with the California Department of Public Health, the agency that licenses nursing homes. For information on how to file a complaint, see CANHR’s Fact sheet, How to File a Complaint Against a Nursing Home.

The most pertinent laws and regulations are found in:

United States Code: 42 USC §1396r(c)(1)(A)(ii)
Code of Federal Regulations: 42 CFR §483.13(a), 42 CFR §483.25(l)
California Code of Regulations: Title 22, Division 5, §72527(a)(5)&(23), §72528(b)&(c)