Having the "Right to Fall"

[TheCommuter]

Am I the only one who thinks state surveyors sound incredibly silly when they make statements such as, "Well, the resident has the right to fall"?

We all have the right to fall as much as we please, but it could turn into an unsafe and potentially deadly situation.

Note: I'm probably too tired to make sense to any of you.

[sanakruz, ADN]

Right to fall?

What BS!

These residents have the right to care and comfort.

The solution is to have 1:1 care for these folks. Right? Someone at the bedside/ chairside 24/7

Now we all know that this will be the day, as it's not "cost effective." The surveyors know this too. But if SNFs were properly staffed, staffed for saftey,these state surveyors would be out of their cushy government jobs.

it makes me bitter...

[nightmare, RN]

Right to fall,oh yeh! One of my residents has exercised that 'right' twice in two months.....result.one #rt n.o.f and one #lt n.o.f.She was recovering so well from the first one as well ,now we'll have to wait and see how she gets on with this one.I'm really sure she wanted to go through all this pain and trauma.Right to fall!!!:angryfire:angryfire just another way of justifying inadequate staff levels to save themselves money!

[jjjoy, LPN]

Please keep in mind that all these rules that seem "ridiculous" now came about because of decades of abuse (restraining clients for staff convenience, punishment, etc.) in the past ... Sure, we all say, "Oh, I would never do anything like that ..." but plenty of people have over the years, and it didn't stop until the authorities made people stop ...

I assure you that no one in government has ever done anything in healthcare regulation proactively -- the rules are all there because of bad things that happened in the past (something gawdawful happened, and the legislature sat up and said, "Golly! We need to make sure that never happens again!)

I see your point. These policies didn't orginate with the intent to be ridiculous. But we humans seem to have this tendency to overcompensate. So yes, we need to find ways to make sure patients aren't restrained all day every day purely for staff convenience. But we also need to make sure that we don't go overboard - which has happened some places in regard to the "right to fall."

Then there's the fact that we don't live in a perfect world. If one elderly person gets strangled in their side rails but 50,000 elderly people avoid falling out of bed and getting a head injury or a hip fracture (which may lead to death through complications), is it worth it to not allow side rails because someone might get strangled in them again at some point?

[bshaw96]

I've never actually heard one say it, but the no restraint policies that are so popular and encouraged in LTC facilities now certainly suggest it. I, having been in LTC 12 years, can't believe how far it's gone. Yes, I have seen instances where restraints were overly used, and used inappropriately. But for the most part, they're not used enough. I can't tell you how many broken hips, broken ribs, a broken nurse, concussions, scalp lacs, and even 1 death I have seen directly attributed to the fact the facility practiced a no restraint policy. Yeah, I guess it's a "right". You have the right to literally break your neck, but you will get a ticket if you drive in your car without a seatbelt. Makes no sense!

[elkpark]

Somehow this discussion always seems to get framed in v. black & white terms of either clients get restrained or they fall and get hurt. It's not at all clear that restraining clients keeps them safer! (In fact, I've always heard "experts" say that it's really about "50-50"; clients are just as likely to suffer an injury from being restrained as they are from not being restrained ...) Here are just a few quick quotes and sources I was able to find in a quick Google search:

"There is no evidence to support the use of restraints for fall prevention. Indeed, restraint use could contribute to serious injuries as a result of a fall." http://www.annalsoflongtermcare.com/article/6319

"While the intended use of restraints is to 'prevent harm,' numerous studies have shown that restraints neither decrease the number of falls, nor ensure freedom from injury. The severity of injury may in fact increase in some restrained patients. http://www.americangeriatrics.org/products/positionpapers/restraintsupdate.shtml

http://biomed.gerontologyjournals.org/cgi/content/abstract/53/1/M47

http://www.annalsoflongtermcare.com/article/951

http://www.annalsoflongtermcare.com/article/6319

[jjjoy, LPN]

Somehow this discussion always seems to get framed in v. black & white terms of either clients get restrained or they fall and get hurt. It's not at all clear that restraining clients keeps them safer!

It's like anything else in health care - each patient situation must be assessed individually. We'll never know for sure if any one patient in any one particular instance would've definitely been more or less safe with or without a posey vest/side rails/low bed etc. If we see a patient fall and crack their head open, we don't know for sure that they wouldn't have strangled themselves on bed rail. If a patient gets strangled by a bed rail, we don't know for sure they otherwise would've survived - they might have fallen and cracked their head open!

Studies can let us know if we might want to shift our practice more way than another (less use of restraints for example). They can challenge our assumptions and give us evidence that we don't have the time or resources to test for ourselves. But just because studies may have shown that at times restraint use can actually cause injuries in some cases doesn't mean that the practice should be thrown out completely. It just needs to be used more judiciously.

[Plagueis]

"While the intended use of restraints is to 'prevent harm,' numerous studies have shown that restraints neither decrease the number of falls, nor ensure freedom from injury. The severity of injury may in fact increase in some restrained patients. http://www.americangeriatrics.org/products/positionpapers/restraintsupdate.shtml

I read this article, and while in the abstract a restraint-free nursing home is the ideal, I don't know if this would work in the "real world." As a CNA, I have seen many residents, for instance, who lean forward most of the time they are in a chair (non-weight bearing), and unless they have someone right there with them, they will lean forward and fall. Trying to remind them not to lean foward in a calm manner, or distracting them with an activity, doesn't work, so, for those residents, unless there is an order for a restraint, they will have to be 1 on 1. I don't think most nursing homes would be willing to hire extra CNAs to sit with a resident 1 on 1 during a whole 8-hour shift.

Also, while having bed alarms is nice, there are residents who are already on the floor/mat when we get to them, even if we try to be there immediately. Will the nursing home hire more CNAs to stay in rooms with residents who are at risk to fall out of bed? I know, residents have the "right" to fall. However, if this is supposed to be the case, why do nurses and CNAs get blamed when a resident does fall, either from management or from family members? If there is a mistake, such as a broken bed alarm, that could have prevented the fall, then I can understand blaming a staff member. However, I don't think that some family members or supervisors themselves always believe the resident-has-the-right-to-fall theory. Especially if the resident tends to jump out of bed/chair, despite being told that they could hurt themselves.

As for the restraint-free nursing homes, if there is anyone who currently works in one, I would like to hear about your experiences, such as if it actually works to reduce injuries to residents.

[CapeCodMermaid, RN]

OKAY...I've been doing this a long time and I remember learning to tie the posey vest straps under the bed so the patient couldn't undo them...I also remember stellazine, thorazine and other not so wonderful drugs.

The state doesn't prohibit the use of restraints but it has to be documented that they are appropriate and the least restrictive method is used. As with so much we do it's all in the assessment process and the documentation. There was one facility around here which got cited during a state survey because they DIDN'T use a restraint. Document document and document some more. The surveyors can't make up their own rules. As long as the documentation is sufficient to show the need for a restraint, you are allowed to use them.

[Simplepleasures]

Wisconsin regs on restraints:

http://www.hpm.umn.edu/NHRegsPlus/state_regulation_attachments/wisconsin_regulation_attachments/wisconsin_subchapter_3_residents_rights_and_protections.pdf

(k) Abuse and restraints. 1. Be free from mental and physical

abuse, and be free from chemical and physical restraints except

when required to treat the resident's medical symptoms and as

authorized in writing by a physician for a specified and limited

period of time and documented in the resident's medical record.

2. Notwithstanding the limitation in subd. 1. for using

restraints only to treat a resident's medical symptoms, physical

restraints may be used in an emergency when necessary to protect

the resident or another person from injury or to prevent physical

harm to the resident or another person resulting from the destruction

of property, provided that written authorization for continued

use of the physical restraints is obtained from the physician within

12 hours. Any use of physical restraints shall be noted in the resident's

medical record. In this paragraph, "physical restraint"

means any manual method, article, device or garment used primarily

to modify resident behavior by interfering with the free

movement of the resident or normal functioning of a portion of the

body, and which the resident is unable to remove easily, or confinement

in a locked room, but does not include a mechanical support

as defined under s. HFS 132.60 (6) (a) 2.

Note: See ss. HFS 132.33, 132.43, and 132.60 (6).

[mercy1975]

The risk benefit statements may be helpful in a lawsuit, but they will not save you from a tag. Even if a resident has mutiple falls, and you have exhausted all interventions, then start over.

The resident's families wishes should not over ride what the facility can do for a resident, such as a new intervention. Easier said than done, right?Maybe the family is not happy with it, but federal regulatons stand on the ground that the facility is responsible.I know this creates alot of issues but you have to look at each one on an individual basis. Have you fully educated the family? These are issues that state will be asking. I know there is no easy solution for resident's families wishes and what the facility should do.

I just wanted everyone to know that you will still receive a tag even if you have a risk benefit statement in place.

[nursesherry]

Oh yes they certainly have a right to fall but it is our responsibility to make sure they aren't injured when they do. How rediculous.

[nightmare, RN]

Oh yes they certainly have a right to fall but it is our responsibility to make sure they aren't injured when they do. How rediculous.

Maybe we need rubber,bouncy flooring!!