Nursing Director removed my pts restraints

  1. So I had a disagreement with my director recently. She was doing her rounding when she came into my pts room. He was in soft wrist restraints for being confused and super violent. The first time I saw him he nicely asked me to come over in a whisper. I came close to the head of the bed and he folded himself in half with remarkable speed and tried to kick me in the face. Among a lot of other things, he was just violent.

    He had been in restraints for 2 days, I saw during my assessment that he was using a lot of accessory muscles in breathing. The acessory muscle usage had also been documented for about a week, but lungs were CTA and great sats. Also, multiple MDs had rounded on him.

    Director saw the accessory muscle use and told me that we're not having a pt die in restraints. I told her I wouldn't go near him without restraints on.

    I go go back in there and he was untied and slipping out of bed. There was no way I was going to help him into bed alone. So I got 2 other people and by the time we came back he was on the floor.

    I was really upset about it because I told her all the things he had done, but she insisted that dying in restraints is a huge deal, and maybe a sitter would be a better alternative. I didnt get in any trouble or anything for the fall, I just think the whole thing was a bunch of nonsense that I really didn't need.
    Last edit by Brian S. on Sep 18
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  2. 37 Comments

  3. by   MunoRN
    If she preferred that the patient have a sitter, did she provide you with a sitter? Sometimes aggressive patients require both a sitter and restraints, I'm not sure what alternative plan she provided?
  4. by   NuGuyNurse2b
    Your director is your textbook A-hole. She let the restraints loose. She then proceeded to leave the pt unattended, knowing full well that he was a danger to himself and others. Then had the audacity to tell you that you should get a sitter for him if restraints cannot be used. If anything happened to him during that time he was unattended, she would've just blamed you.
  5. by   remotefuse
    My original post isn't really asking a question. for one I wanted to share the experience. I do understand my directors concern with policy, but I don't agree with her putting me or a sitter in the way of violence, leaving the pt unattended, or not actually telling when she did it.

    what would have been the best way for me to handle this situation?


    I also also want to share that I have more bedside care experience than my director. She started on our floor as an LPN as her first nursing job. Went from LPN-RN-charge-manager in like 3 years. After like 2 years as a manager she became director. And I didn't think death was imminent for the pt.
  6. by   MunoRN
    Personally, I would have handled it by reporting the actions of your nursing director to the BON as they were pretty clearly negligent, but then again I'm a trouble maker.
  7. by   gcupid
    Quote from remotefuse
    So I had a disagreement with my director recently. She was doing her rounding when she came into my pts room. He was in soft wrist restraints for being confused and super violent. The first time I saw him he nicely asked me to come over in a whisper. I came close to the head of the bed and he folded himself in half with remarkable speed and tried to kick me in the face. Among a lot of other things, he was just violent.

    He had been in restraints for 2 days, I saw during my assessment that he was using a lot of accessory muscles in breathing. The acessory muscle usage had also been documented for about a week, but lungs were CTA and great sats. Also, multiple MDs had rounded on him.

    Director saw the accessory muscle use and told me that we're not having a pt die in restraints. I told her I wouldn't go near him without restraints on.

    I go go back in there and he was untied and slipping out of bed. There was no way I was going to help him into bed alone. So I got 2 other people and by the time we came back he was on the floor.

    I was really upset about it because I told her all the things he had done, but she insisted that dying in restraints is a huge deal, and maybe a sitter would be a better alternative. I didnt get in any trouble or anything for the fall, I just think the whole thing was a bunch of nonsense that I really didn't need.
    welcome to nsg LoL! Complete foolishness! I bet her directing self wouldnt have taken him out of restraints if she had to take care of him.
  8. by   NurseCard
    I don't know how else you could have handled it. If the patient truly demonstrated
    the need to be in restraints for 2 straight days, and had the proper orders and
    documentation in place, then it certainly wasn't her place to just go in there,
    take the restraints off, and then just walk out... and she didn't even tell
    anyone!!!

    I mean, I agree that a sitter is better, or maybe some Haldol and a
    sitter .. but again, if the restraints were ordered, all protocols being followed..
    your DON is negligent.
  9. by   Here.I.Stand
    A year or two ago, I had a pt who transitioned to comfort care, and was dead within an hour of extubating. It was around 7p-8p -- so later in the day when we extubated. I called the ME's office to report the death, and got the voicemail.

    One info piece that recorded message asked us to leave was "was the pt in restraints within 24 hrs of death?"

    I think I said "She had had soft wrist restraints on while still intubated. However her death had nothing to do with her restraints, and everything to do with the undiagnosed CA that had eaten through her peritoneam."

    Super obnoxious of your DON though! Prioritize a potential risk from restraints, over the current danger if the pt clocking someone. And as another poster said, if he wanted a sitter, a sitter should have materialized...altough the sitter would need to be safe as well, so they might well need the restraints as well.
    Last edit by Here.I.Stand on Sep 17
  10. by   remotefuse
    Quote from Here.I.Stand
    A year or two ago, I had a pt who transitioned to comfort care, and was dead within an hour of extubating. It was around 7p-8p -- so later in the day when we extubated. I called the ME's office to report the death, and got the voicemail.

    One info piece that recorded message asked us to leave was "was the pt in restraints within 24 hrs of death?"

    I think I said "She had had soft wrist restraints on while still intubated. However her death had nothing to do with her restraints, and everything to do with the undiagnosed CA that had eaten through her peritoneam."

    It is a big deal in my state. If someone dies in restraints, it becomes a ME case. There's a ton more
    Paperwork even if we say the restraints were not the cause.

    I get her concern, but I'm not getting kicked in the face for anything. The soft restraints were the only thing keeping him from making contact with me multiple times that day.
    PChemical restraints didn't work for him and he was just incredibly violent. Also, his breathing was worth noting, but he wasn't declining. It had been his baseline since we had him. She just didn't care about us getting hurt and that's just what really bothered me. I'm telling her, he literally tired to kick me in the face, and that carried no weight. Her paperwork and protocols were the only thing she cared about.

    ** edit that's not really fair, she did go on and on about the lack of dignity in dying in restraints, but still... he was just an incredibly violent/confused pt.
  11. by   JKL33
    Things I would do:

    Contact MD pronto. This patient's situation needs to be medically optimized and regardless of what hasn't worked so far, the physician needs to be actively involved in the situation of a violent patient.

    Verbalize understanding of the director's concerns/pov, and then state that we will need to utilize the restraints until the sitter is in place AND the situation is controlled (through use of medications if necessary)

    Brainstorm for any and every intervention that might reduce stimulation and/or increase pt comfort (noise, lights, soothing music, correct ambient temperature, assess for pain, thorough physical assessment looking for correctable reasons for agitation, etc., etc.)

    Utilize the facility's incident reporting system - for both the fall and the fact that the restraints were removed by [Name] at [Time].

    Document the events chronologically, including removal of restraints by [Name].

    Report up the chain of command

    Sorry you are dealing with this
  12. by   Nurse Beth
    The Director acted out of fear of getting in trouble and not out of concern for anyone else, including the patient.
  13. by   FolksBtrippin
    It was unconscionable for her to take him of restraints without you present, aware and ready for plan B.

    But there are some more problems.

    Patients who need restraints for violence need 4 pt locked velcro restraints, not soft wrist restraints. Soft wrist is for pts who are confused and pulling on their tubing.

    If you can't do 4 pts locked Velcro like we do in psych, then soft wrist is not an alternative for a violent patient with the capability of kicking someone and folding his body in half like you describe. This kind of pt could get hurt or even die in soft wrist restraints.

    So you need another option if 4 pts are not available. Even if 4 pts are available, you need a new med order.

    If no meds are keeping him calm, you haven't found the right med yet.

    Haldol is a caution in the elderly and I'm guessing you've got a standing order for ativan, but have you tried thorazine, vistaril, benadryl or maybe even depakote?

    Call the doc and get this guy some new prns.
  14. by   BSNbeDONE
    Quote from Nurse Beth
    The Director acted out of fear of getting in trouble and not out of concern for anyone else, including the patient.
    ^^^^Yes. A search of the CMS website regarding restraints will provide insight. A restrained individual such as the OP described is a danger to himself in and out of restraints. While in restraints, there are subjective risks to the patient: anxiety, panic, increased stress and strain on the heart, etc.

    Being out of restraints, well, it's obvious what will happen. The director would prefer that her staff do the explaining instead of herself...even if it resulted in physical injuries that could have been avoided. What she fails to realize is that, as a director, she is still responsible for what happens in that case as well.

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