Can you define physical restraint for us and provide examples?
A physical restraint is defined as "any manual method, physical or mechanical device, equipment or material, that meets all of 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/her body."
What does convenience mean, with relation to restraints? Convenience is defined as "the result of any action that has the effect of altering a resident's behavior, such that the resident requires a lesser amount of effort or care and is not in the resident's best interest." In other words, it is for the benefit of the staff, not for the resident.
Discipline is defined as "any action taken by the facility for the purpose of punishing or penalizing a resident."
Freedom of movement means "any change in place or position for the body or any part of the body that the person is physically able to control." The person may not be safe standing or they may not be safe walking by themselves, but they still have that right to do so. We, as an interdisciplinary team, need to figure out how we can help that person to be safe.
Manual method means "to hold or limit a resident's voluntary movement by using body contact as a method of physical restraint."
A medical symptom is defined as "an indication or a characteristic of a physical or a psychological condition."
Position-change alarms are "alerting devices intended to monitor a resident's movement. The devices emit an audible signal when the resident moves in certain ways. They can be attached either to the bed or chair or onto someone's clothing." These alarms can be considered restraints. Coming up, we will discuss position-change alarms in more depth.
Finally, removes easily means that "the manual method, physical or mechanical device, equipment or material, can be removed intentionally and upon command by the resident in the same manner as it was applied by staff." The physical condition and cognitive status of the resident may come into play here, as to whether or not they can remove the restraint. For example, a bed rail is considered a restraint if the resident is not able to put the rail down in the same manner as the staff does. A lap belt is considered a restraint if the resident cannot intentionally release the belt buckle. If, after three hours of fidgeting, the lap belt comes off the resident, that is not removing easily; that is fidgeting. There is a definite distinction between the two.
Examples of Physical Restraint Practices
Examples of facility practices that meet the definition of restraint include, but are not limited to:
- Bed rails that keep a resident from getting out
- Placing a chair close to a wall, heavy table, or other barrier to prevent rising
- Using a concave mattress that the patient cannot get out of
- Tucking in a sheet tightly so it prevents movement; fastening fabric or clothing in such a way that freedom of movement is restricted
- A chair that prevents rising (bean bag chair, recliner or Geri chair)
- Devices such as trays, tables, cushions, bars, belts
- Arm restraints, hand mitts, soft ties, vests
- Holding a resident down in response to behavioral symptoms, or when they refuse care
- Placing a resident in an enclosed, framed, wheeled walker that cannot be opened (e.g., MerryWalkers)
- Some position change alarms
- Reclining geri-chair
- Upright geri-chair with lap tray
- Devices that “hold” resident in the chair
- Seat belt, not self-releasing
- Lap buddies that cannot be removed
Examples of Convenience: Physical Restraint
It's important to recognize that we cannot impose any sort of physical or chemical restraint for the purposes of discipline or convenience. Furthermore, the facility is prohibited from obtaining permission from the resident or the resident representative (e.g., the family member) for the use of restraints when the restraint isn't necessary to treat a medical symptom. For example, in cases where the family members indicate that they want you to use a lap belt, if it is not being utilized to treat a medical symptom, we shouldn't be putting that in place. The families or resident representatives cannot dictate when we do or do not restrain. To reiterate, restraints should only be imposed when they are required to treat a medical symptom.
Examples of convenience include, but are not limited to:
- Staff are too busy or have too high a workload to monitor the resident
- Staff believes that the resident does not exercise good judgment; they forget their physical limitations when they are standing or walking, or they don't ask for assistance appropriately
- Staff state the family has requested restraint to prevent falls, particularly during high activity times (e.g., meals, shift change, medication pass)
- Not enough staff
- Temporary staff do not know the resident or don't know how to approach the resident (e.g., if they have dementia or related behaviors)
- Lack of staff education regarding restraint alternatives
- Teaching the resident a lesson
- Preventing wandering
- In response to confusion or combative behavior, such as during ADLs (e.g., showers, clothing changes); holding down resident's arms or legs to complete the care
Now, there are cases where a resident needs to be restrained during an emergency situation. For example, the staff may briefly hold a resident down for the sole purpose of providing necessary, immediate, life-saving medical care that has been ordered by a physician. If we're focused on providing good resident-centered care and good nursing care, these issues don't come up. When we lose that focus, issues of convenience tend to arise.