Man dies after falling out of bed wearing a vest restraint

[HappyNurse2005, RN]

http://www.roanoke.com/news/roanoke/wb/56224

The start of the article

Lewis-Gale Medical Center in Salem has curtailed use of physical restraints after the death of an elderly patient who slipped out of bed between hourly nursing checks even though he was wearing a restraint vest.

The state medical examiner's office in Roanoke said Clayton Golyzniak, 83, died from a subdural hematoma, a condition involving blood on the brain, for which he had surgery Nov. 30.

However, restricted breathing was a contributing factor in his death. In a rare medical mishap, Golyzniak was found on or near the floor suspended by his restraint vest with part or all of the vest "slung around his neck," according to incident records.

For the record, i DO NOT work at this facility. I have no personal knowledge of this. I just read it in the newspaper

[clee1]

Great..... So, one fatal accident is going to change/restrict the use of restraints. How many fx hips is that going to result in? Lord knows, TPTB aren't going to pay for more staff to watch these folks more closely.

[Noryn]

This isnt the first time this has happened. Vest restraints should only be used when there are full length side rails or they do make boards you can place on the split side rails to keep people from being able to do this.

This started in my area around 2000 and when I moved to a different location they thought I was crazy until I pulled the information up straight from the posey website.

[veegeern, BSN, RN]

We had a patient manage to do something similar w/o injury b/t hourly checks WITH A SITTER at the bedside. . . She was sleeping "because the patient was restrained."

[elkpark]

The only thing remarkable about the incident is that it got any publicity. This sort of thing (not death, necessarily, but certainly injury related to restraints) happens much more frequently than people realize -- it has always been highly debatable whether restraining people is actually any safer than just leaving them "loose."

[suzanne4, RN]

That is why a vest restraint should be used only as a last attempt, not the first for the convenience of the staff. And checks should be every fifteen minutes, not one hour when they are in the vest. Much easier and cheaper for the facility to have a 1:1 sitter that stays awake. This lawsuit is going to cost them much more.

Even with wrist restraints, there is supposed to be a check done every fifteen minutes, and this is per JCAHO regulations. That hospital may as well sign away the facility, they were 100% wrong in everything that is written about this case so far, a good attorney is going to have a field day with this.

This is why documentation is so very important.

[tridil2000, MSN, RN]

we should just put confused pts in big cribs.... like we do with babies!

[caroladybelle, BSN, RN]

Great..... So, one fatal accident is going to change/restrict the use of restraints. How many fx hips is that going to result in? Lord knows, TPTB aren't going to pay for more staff to watch these folks more closely.

ONE FATALITY?

I suggest you check the stats on this.

In the state of Florida, alone, in one year, there were 7-10 fatalities from use of restraints. I only know this from one of those required CEUs about medical errors.

Unfortunately, you are right about the staffing issue. In the few places, I work that use sitters, invariably the sitter is pulled from regular staff. Which means that the remaining staff were spread even thinner, resulting in.......more falls because they cannot answer the call lights quickly enough.

It will be nice when the law makers that create regulations, actually have to provide financial support for them.

[caroladybelle, BSN, RN]

we should just put confused pts in big cribs.... like we do with babies!

Try making that suggestion in a letter to the Editor of the AARP newsletter, or the florida newspapers.

But put on your flameproof suit first and insure your home heavily against arson.

[chadash]

Those vest restraints are NOT for the convenience of the staff, that is for sure. You really have to watch them much more (like the earlier post said, every 15 at least) and I think a sitter is a very good idea with these restraints.

But it would be nice to have a conscious sitter!

Like meds and what not, you got to follow through with all the precautions.

It is a shame, cause sometimes this is really needed.

[zacarias, ASN, RN]

Restraints are totally on their way out. I can't believe this happened at a hospital. In a vest restraint you MUST have limb restrains on too to reduce risk. Also, a vest restraint is LAST RESORT among A MILLION other possible interventions, including simple haldol.

I agree with Suzanne. This facility could be in deep trouble.

[pediatriclpn]

You have to watch the use of meds as chemical restraints, also. Esp. in nursing homes, or dealing with the mentally challenged. And if you have to check on someone in a restraint every 15 minutes, they might as well glue their bed to your butt. I don't think there is a place on earth that has the staff to be able to realistically do that.