Man dies after falling out of bed wearing a vest restraint

[HappyNurse2005]

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

[BRN]

How sad for the family. This did not have to happen. I once worked at a place where a staff member applied a vest restraint and tied it to the bed, so when the HOB was raised it choked the patient. The patient had bruising on his neck he was lucky it did not kill him.

Sadly, many patient families do not want to be bothered with sitting with their family members and sometimes the nurse does not even approach the family b/c they feel it is easier to restrain than to find help.

[postmortRNhere]

I am shocked...I don't have much experience with those vest restraints, nonetheless it is disturbing. I agree with Suzanne also.

[gr8rnpjt, RN]

I witnessed a similar incident 19 years ago. The other nurse on nights had this patient in a posey vest restraint, double siderails. She somehow contorted her body and ended up with her face smashed between a pillow and the mattress inside the siderail. It was the worst thing I ever saw. While we were calling the code and trying to get her un-contorted, the other nurse just kept saying, "How could this happen? I just checked on her a few minutes ago, I don't understand" She was horrified. I still can't figure out how it happened.

[froghair]

How sad for the family.

Sadly, many patient families do not want to be bothered with sitting with their family members and sometimes the nurse does not even approach the family b/c they feel it is easier to restrain than to find help.

very good point. alot of families wouldnt be willing to sit with them but you can be sure if anything happens there straight to the lawyer.

those vests have been banned out here for a while and the use of bed rails is also on the way out. there is no easy answer as you cant be with a patient 1 on 1 24/7

[LPN1974, LPN]

The last NH I worked in was restraint free.

They implemented the use of low beds and pads by the bed in case they fell out.

We still had injuries tho, on people who fell, but no deaths from restraints, because there were none.

Very sad case. If it were MY grandfather, I would be heart broken.

ONE death is one death too many, IMO.

[chadash]

The last NH I worked in was restraint free.

They implemented the use of low beds and pads by the bed in case they fell out.

We still had injuries tho, on people who fell, but no deaths from restraints, because there were none.

Very sad case. If it were MY grandfather, I would be heart broken.

ONE death is one death too many, IMO.

a mattress on the floor really works, at least it slows them down a bit! :)

Put an alarm on them, and you'll beat them to the punch every time (if you run!)

I heard somewhere though that a mattress on the floor was considered a restraint.

Are lap buddies a restraint? They are great for folks who sort of just pitch forward. Again, supervision is so important, they can slide and catch their necks. Seems if it can happen, it will happen.

My unlearned opinion is that restraints, used properly, when absolutely needed can be a good thing, but never never to replace supervision. I don't think it is a good idea to alow someone on restraint out of eye shot for any amount of time.

[Tweety, BSN, RN]

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.

Good post. Restraint deaths are too many in our nation.

We had a restraint death with a belt in our facility that devasted us last year. (Yes it made the papers like this one did, and yes my facility got sued, along with five employees, and we were investigated by the state). Even one fatality is too much. Our manager, even though it didn't happen on our unit, tried to go restraint free, and use more sitters and bed alarms. The bed alarms dramatically decreased restrain use, but we had to go back to using restraints due to staffing, but we don't use belts, just soft wrist. There are times for the safety of the patient it's necessary, so I'm not sure about government legislation.

[chadash]

Good post. Restraint deaths are too many in our nation.

We had a restraint death with a belt in our facility that devasted us last year. (Yes it made the papers like this one did, and yes my facility got sued, along with five employees, and we were investigated by the state). Even one fatality is too much. Our manager, even though it didn't happen on our unit, tried to go restraint free, and use more sitters and bed alarms. The bed alarms dramatically decreased restrain use, but we had to go back to using restraints due to staffing, but we don't use belts, just soft wrist. There are times for the safety of the patient it's necessary, so I'm not sure about government legislation.

I think you have really put this in balance.

[Nightcrawler, BSN, RN]

I have always hated restraints. EVERY time that I have been hit, or kicked, or scratched, or bit, it has been by a patient in restraints. Vests get pulled up under the arms, they slide down in bed, and the next thing you know their entire lower body is hanging over the side of the bed and they are kicking you as you try to solve the situation. I have been known to sit at a patient's doorway and do paperwork all night, leaving a patient unrestrained, even with orders, and only apply the restraints if I have to leave for a few minutes and no one else is available. The patient stays much calmer and I have the order for the restraints if I need them. Also I only have to fill out the pile of paperwork for restraints if I actually use them!!!!

[DhornRN]

I've often wondered why there aren't more beds literally on the floor? It seems that this may be a solution for those confused patients who can't walk but can wiggle enough to fall out of bed.

[caroladybelle, BSN, RN]

Sadly, many patient families do not want to be bothered with sitting with their family members

Please don't say this.

There are families being devastated by the stress of taking care of their elderly or mentally/physically incapacitated members.

There are the wo/men that are literally isolated in their homes, taking care of loved ones that sometimes lapse into abusive behavior. Imagine trying to work fulltime, take care of yourself and your spouse/kids and keep a constant eye on mom/pop or have around the clock caregivers.

Quite frankly, most of them desperately need the break from the stress, before the stress destroys them and their families.

Postop, I had several weeks of total hell, with my mother. She would continually get up without calling and had several falls. She also weighs over 300#. As she had a repair of the right rotator cuff, I could not possibly lift her off the floor. I couldn't sleep, for fear that she would get up, and yet was working fulltime to pay our bills. Live like that for a few weeks, and see what is does to you. I was "on" 24/7, and was close to losing it, even with my "break" to work.

And, no it is not like dealing with kids - you have a certain amount of authority with them. It is easier to change their diapers, bath them. And your parents do not "outgrow" this stage.

It is rare that they "do not want to be bothered", more often that their bosses will fire them if they call in again, they are on the verge of a breakdown from no sleep and high stress, or worried about divorce from the stress on their marriage.

They really need that break.

There is really no good solution. In the Old days, people kept their elderly home......but people also did not live on in poor health for decades. Our advances in healthcare has many people living with mental and physical disabilities that would never survived, previously.

[not now, RN]

I've often wondered why there aren't more beds literally on the floor? It seems that this may be a solution for those confused patients who can't walk but can wiggle enough to fall out of bed.

I've got a woman at my facility who will take off her personal alarm (or carry it in her hand), get up from her low bed (that has a concave matress), walk herself to the bathroom and back before anyone knows the wiser. I caught her this evening. I looked up from my med cart and there she was leaving the bathroom. She smiled and waved as she shut the door.

Another man (two contractured legs and a contractured arm) would fling himself from the low bed, off the mattress on the floor and wouldn't start yelling until he had scooted himself to the middle of the room. I could never figure out how he did it. Couldn't put a personal alarm on him because he refused to wear a shirt. I made sure he was checked every 15 minutes.

Another woman has fallen so many times regardless of lowbeds, concave matresses, personal alarms that I pad her Geri-chair, tilt it all the way back, give her a pillow and blanket, slap on the personal alarm and park her in the lobby directly in front of the nurses station. She won't sleep in her bed. When she could still ambulate well she'd refuse to sleep in her room and park herself on the couch so I figure she likes it out there. Sleeps for me everynight. When she starts to squirm I know she needs to use the restroom and someone walks her.