Can you define chemical restraints and provide us with some examples?
A chemical restraint is defined as any drug that is used for discipline or staff convenience, and not required to treat the medical symptom. If we're going to use a chemical restraint, we need to use the least restrictive alternative for the least amount of time, provide ongoing re-evaluation of the need for the medication, and not use that medication for discipline or convenience.
Chemical restraints are commonly used because of behaviors, particularly dementia-related behaviors. You may be thinking that it is outside of our scope of practice as therapists to look at some of these medications. However, it is most definitely within our scope of practice to provide alternatives for those behaviors. As therapists, we have a huge opportunity to come in and recreate the environment and figure out a cuing strategy and come up with non-pharmacological solutions, versus resorting to a medication. While the meds are not within a PT's scope, all of those other non-pharmacologicals that CMS is looking at are certainly within our scope.
The definitions for convenience, discipline and medical symptom as they relate to chemical restraints are the same as for physical restraints. The indication for use, however, is defined as "the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident’s condition and therapeutic goals and is consistent with manufacturer’s recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review articles that are published in medical and/or pharmacy journals." Essentially, that's Medicare's way of saying that chemical restraints are not acceptable. We need to find non-pharmacological interventions, instead of relying on these types of medications.
Some examples of chemical restraints include antipsychotics, antidepressants, antianxieties, and sedatives: things that are not used to treat a medical condition. Again, when you're in long-term care, if you look at the minimum data set (MDS) that facilities are completing, they're looking at these examples and the requirements are pretty strict right now that we can no longer do PRN orders for these medications. There needs to be a lot of documentation in place to use them.
Examples of Convenience: Chemical Restraint
Other examples of facility practices that indicate a medication (ordered by a practitioner) is being used as a chemical restraint for staff convenience or discipline include, but are not limited to:
- Staff indicate that a medication is being administered based on the resident’s representative’s request to administer a medication to “calm down” the resident
- Staff have recommended to the practitioner that a resident be administered a medication in order to prevent a resident from displaying behaviors such as wandering into other resident’s rooms
- Staff administer a medication to quiet the resident because the resident continually calls out, without attempting alternative interventions
- Staff become frustrated with a resident who continually requests staff assistance (such as for toileting), or continually puts on the call light, and administer a medication to sedate or subdue the resident
- Staff administer a medication that subdues or sedates a resident when insufficient staffing levels do not allow for the resident’s needs to be met
- Staff administer a medication to sedate or subdue the resident, and/or to restrict the resident to a seated or lying position since the resident continually wanders into other resident’s rooms or attempts to leave the unit
- Staff becomes upset with a resident who resists receiving a bath and pinches staff. The staff had neither re-assessed the resident nor revised interventions regarding how to provide bathing care in order to meet the resident’s needs. Instead, of using good person-centered care, staff administer a medication that is used to subdue the resident prior to providing the bath, but the medication is not used to treat an identified medical symptom.