Need your opinion about restraint reduction

Long Term Care Columnist / Guide · Apr 6, 2005

Ok, now I have just been to a meeting at my job. I am a LVN in a total Alzheimers facility, owned by Lifecare Centers. So if you are employed at one of there many facilities I would love to hear from you on your facility stats. I am also looking for the opinion of anyone that will answer. Our corporate office has decided that our facility is going to be restraint free. Now the people that have soft belts will be reduced and now they will have self release belts. Which would be OK but they have soft belts because they removed the self-release belts and had a injury of some sort. I am all for having the least amount of restraint possible , but some of these patients are a HIGH fall risk. My boss says that we will have a increase in incident reports and may have some injuries . However, we have to reduce the amount of restraints because all the other Lifecare centers are restraint free. It doesnt seem right to me to risk a patients saftey in order to market a restraint free facility. It was not long ago the state come in and had us remove several restraints in the building . One lady fell out of her W/C , broke her hip then died two weeks later. These are dementia patients with very short term memories. I would love to hear how others handle this situation in other facilities.:)

Don'tcha just love it when the corporate folks, who wouldn't know a soft belt from a hangman's noose, tell you how it's going to be? :angryfire It's one reason why I left LTC.......an increase in incident reports and injuries was the least of my problems when my last SNF went restraint-free. How about some nice, big, fat lawsuits? Families pay big bucks to keep their loved ones in these places, and the least they expect is that the staff will protect them from harm. They have no idea that facilities cannot possibly employ enough workers to watch their mom or dad 24/7, or that the corporate people are the ones responsible for making the policies that prevent staff from keeping them safe........all the families care about is that broken hip, that closed-head injury that put Papa in a coma, that bruise on Mamma's wrist.

OK, now that I've had my rant :chuckle .........Your corporate mucky-mucks have made the decision, now your facility will have to join the 21st century and learn to deal with it. What your facility needs to do is develop a fall prevention protocol. This should include definitions of what is and what is not a restraint, resident fall risk assessment guidelines and parameters, training for staff in preventing falls, a list of drugs commonly given to the elderly that can cause falls, and alternative methods of prevention, e.g. personal alarms, medication changes, the use of Hollywood (low) beds and mattress pads on the floor, and so on.

You will also want to notify all of your residents' families as to the changes, and enlist their help to make the transition to restraint-free living. Most will be happy about this---no one likes to see their loved one tied into a chair or a bed---but you'll get resistance from a few, who will sneak in when you're not looking and tie a robe sash around Grandma's waist when she's up in her wheelchair (it never fails to happen when State walks into the building :uhoh3: ) or insist that they are PAYING to keep their dad there and he WILL have side rails on his bed, or else!!

Good luck to you.......you'll need it!

CapeCodMermaid, RN · Apr 6, 2005

We've really cut down on the number of restraints we use, but there are some people who still need them. We have a restraint meeting, get signed consents and try to reduce as much as we can. One of the facilities around here was cited by the DPH for NOT using a restraint on someone who clearly needed one, so it seems you can't win.

Antikigirl, ASN, RN · Apr 6, 2005

We also have a group that oversees all the incident reports and tries to trouble shoot falls and other injuries on top of what the nurses have suggested. They meet weekly, and it is really helpful because you know that they are really trying to lower the number of incidents and following up.

Now, we are allowed to use 1/2 rails if we can prove to state that it is a last resort, and really is a safety issue. It is a very long complicated process that takes about a full month to implement, but we can do it if we find there are no other alternatives.

My group has got just about all fall risk folks on alarms with baby monitors, bodypillows, mattresses on floors, we have suggested futons (beats just a mattress on the floor), marry walkers with padding and tactile stimulation items on the bars so they touch and feel those instead of trying to undo the locks, stress balls they can squeeze when they are feeling anxious (I can't believe it but they really work!), etc... We also go through the rooms removing clutter or large funiture pieces that are causing probelms, pad corners, watch medications to see if they are really necessary (which most are, but we ask anyway), and try really hard to involve family in these issues so they too can help brainstorm and probelm solve.

debbiemig · Apr 6, 2005

I believe it is a Federal Law not to restrain residents. We did this in our 300 bed facility several years ago. What a uprising we had, staff and family members. What we had to do was be more creative in fall prevention! We have low beds on most of the units. We have floor mats. We have electric beds with half side rails. At one point the State objected to the half siderails. I always felt that they were an assistive devise ( especially since I'm getting older and find getting up at night sometimes requires a little boost!). We do have velcro belt restraints. As long as they can open them, they aren't considered restraints!We have chair and bed alarms. I would suggest not to purchase the alarms that attach with a string. I would suggest the under the seat or under the mattress alarms. They are much more effective. The ones with the strings go off with a high pitch noise that sometimes sounds like someones cell phone, the string allows them to be already on the way to the floor when it sounds! So basically it's calling you to help someone off the floor! Then we have an increased activity program. They work until about 8 pm. So by the time the residents go to bed, they are tired and sleep!

It has been a big trasition, but overall it has been a very good thing!

Ok, now I have just been to a meeting at my job. I am a LVN in a total Alzheimers facility, owned by Lifecare Centers. So if you are employed at one of there many facilities I would love to hear from you on your facility stats. I am also looking for the opinion of anyone that will answer. Our corporate office has decided that our facility is going to be restraint free. Now the people that have soft belts will be reduced and now they will have self release belts. Which would be OK but they have soft belts because they removed the self-release belts and had a injury of some sort. I am all for having the least amount of restraint possible , but some of these patients are a HIGH fall risk. My boss says that we will have a increase in incident reports and may have some injuries . However, we have to reduce the amount of restraints because all the other Lifecare centers are restraint free. It doesnt seem right to me to risk a patients saftey in order to market a restraint free facility. It was not long ago the state come in and had us remove several restraints in the building . One lady fell out of her W/C , broke her hip then died two weeks later. These are dementia patients with very short term memories. I would love to hear how others handle this situation in other facilities.:)

Antikigirl, ASN, RN · Apr 7, 2005

One of the reasons we can use bed rails is if we can prove that the patient needs them, or CNA's need the patient to be able to use them for transfers or position changes and the like. We have to prove that we have used other methods and the siderails are the best alternative. We do put body pillows along them for padding and does detour people from climbing over them or hitting them, or getting any tubes caught in them (there is a big scare that some foley tube is going to choke a patient if it was to get caught).

We also use those alarms that go under patients, they are wonderful and work much better than the pull string ones! There are also magnetic ones, but I don't like those very much.

msdunn · Apr 8, 2005

:uhoh21:

Ok, now I have just been to a meeting at my job. I am a LVN in a total Alzheimers facility, owned by Lifecare Centers. So if you are employed at one of there many facilities I would love to hear from you on your facility stats. I am also looking for the opinion of anyone that will answer. Our corporate office has decided that our facility is going to be restraint free. Now the people that have soft belts will be reduced and now they will have self release belts. Which would be OK but they have soft belts because they removed the self-release belts and had a injury of some sort. I am all for having the least amount of restraint possible , but some of these patients are a HIGH fall risk. My boss says that we will have a increase in incident reports and may have some injuries . However, we have to reduce the amount of restraints because all the other Lifecare centers are restraint free. It doesnt seem right to me to risk a patients saftey in order to market a restraint free facility. It was not long ago the state come in and had us remove several restraints in the building . One lady fell out of her W/C , broke her hip then died two weeks later. These are dementia patients with very short term memories. I would love to hear how others handle this situation in other facilities.:)

several years ago our facility decided to go restraint free also; as a new ltc director i was at a loss to figure out the easiest way to accomplish this without all of the "old timers" walking out on me, we decided it was easier to watch everybody than to remember who had restraints and who did not; we took them all off at once, the falls did increase; but were less severe; we actually had a decrease in injuries and the residents were and still are much happier; that was 13 years ago; we still have no restraints, we still have falls, we still have fractures, etc. but none as severe as before; we have lost some residents because the families wanted restraints and we refused; they moved to another facility.

good luck; it can be done; and should be done.

studious · Apr 12, 2005

We are not allowed to restrain any patient any time any place anyhow. This includes chemical restraint as well. I am in a different country though. We employ the use of safe hips, a pair of underwear that has shock absorbant thigh protectors, to reduce the risk of fracture around the femoral region. The use of safety rails in bed at night, no no. We have to assess a patients risk of climbing out of bed, if they do, safety rails are left off, due to the extra height a patient can fall if they are in place. Safety rail bumpers need to be in place for people who qualify for them in case of strangulation or skin tears if there legs get through. We implement beds that wind right down to the floor, so the patient cannot "fall out of bed". If a patient is at risk of harming themselves or others whilst in bed, we put socks over their hands, but even then a Doc has to document in medical notes, and relatives have to agree after an informed meeting has taken place with Doc and Nurse. Chemical restraint can only be given during times of great distress for a patient, even then it is short term and is reviewed daily or weekly. Chemical restraint is often a catalyst in falls, due to problems with hypotensive episodes. Stands to reason that patients with Alzheimers may have periods of insight that leads to fear and distress Yes! even aggression. This needs to be managed more sensitively. Being strapped in to a chair, would certainly drive me even more bonkers, and I would lash out, the same as I would if a nurse tried to put me in a bath at 7am. The odd scrape and bang, well we manage with a few bandaids or steristrips or bandages. Unfortunately there is even more paperwork. Patients need to wander where they want to go, but if they are happy, who cares. The door alarms are constantly going off in our facility, or buzzers being rung 'cause wee Molly(not patients real name) has got lost or forgotton what room she's in. Sometimes I am surprised and comforted by relatives when I explain the reasons for not restraining their relative, i.e no quality of life, lack of exercise leading to lean muscle mass, ultimately leading to pressure ulcers. Open windows and doors, did anyone see the awakenings, it can really happen you know, and not just for people who suffer Parkinsons. Chemical induced hazy fog is no life. Can it really be justified???? Please don't tell me about lack of staff. I've worked in LTC for twenty years. All of the above are the National Standards in Great Britain, or part of local policy. Long gone are the days of restraining patients over here, either chemically or physically. Ward management needs to change, structure and overall institutionalised belief needs to stop. This is the 21st century after all. Get them off their drugs, and let them be human, dementia or not. Sometimes you get a glimpse of how they used to be. People should only be on antipsychotics if they are really psychotic. They may just be afraid and a bit confused. Just swap one treatment for another. If restraint is required, the doctor should be informed and the reasons why clearly written down in the medical notes. We should in this day and age be finding more therapeutic ways of managing these illnesses I think anyway. Please don't slate me, I'm, just used to working a different way when dealing with dementia and alzheimers.

msdunn · Apr 13, 2005

We are not allowed to restrain any patient any time any place anyhow. This includes chemical restraint as well. I am in a different country though. We employ the use of safe hips, a pair of underwear that has shock absorbant thigh protectors, to reduce the risk of fracture around the femoral region. The use of safety rails in bed at night, no no. We have to assess a patients risk of climbing out of bed, if they do, safety rails are left off, due to the extra height a patient can fall if they are in place. Safety rail bumpers need to be in place for people who qualify for them in case of strangulation or skin tears if there legs get through. We implement beds that wind right down to the floor, so the patient cannot "fall out of bed". If a patient is at risk of harming themselves or others whilst in bed, we put socks over their hands, but even then a Doc has to document in medical notes, and relatives have to agree after an informed meeting has taken place with Doc and Nurse. Chemical restraint can only be given during times of great distress for a patient, even then it is short term and is reviewed daily or weekly. Chemical restraint is often a catalyst in falls, due to problems with hypotensive episodes. Stands to reason that patients with Alzheimers may have periods of insight that leads to fear and distress Yes! even aggression. This needs to be managed more sensitively. Being strapped in to a chair, would certainly drive me even more bonkers, and I would lash out, the same as I would if a nurse tried to put me in a bath at 7am. The odd scrape and bang, well we manage with a few bandaids or steristrips or bandages. Unfortunately there is even more paperwork. Patients need to wander where they want to go, but if they are happy, who cares. The door alarms are constantly going off in our facility, or buzzers being rung 'cause wee Molly(not patients real name) has got lost or forgotton what room she's in. Sometimes I am surprised and comforted by relatives when I explain the reasons for not restraining their relative, i.e no quality of life, lack of exercise leading to lean muscle mass, ultimately leading to pressure ulcers. Open windows and doors, did anyone see the awakenings, it can really happen you know, and not just for people who suffer Parkinsons. Chemical induced hazy fog is no life. Can it really be justified???? Please don't tell me about lack of staff. I've worked in LTC for twenty years. All of the above are the National Standards in Great Britain, or part of local policy. Long gone are the days of restraining patients over here, either chemically or physically. Ward management needs to change, structure and overall institutionalised belief needs to stop. This is the 21st century after all. Get them off their drugs, and let them be human, dementia or not. Sometimes you get a glimpse of how they used to be. People should only be on antipsychotics if they are really psychotic. They may just be afraid and a bit confused. Just swap one treatment for another. If restraint is required, the doctor should be informed and the reasons why clearly written down in the medical notes. We should in this day and age be finding more therapeutic ways of managing these illnesses I think anyway. Please don't slate me, I'm, just used to working a different way when dealing with dementia and alzheimers.

Sounds like my type of LTC; I agree the chemical restraints are as bad or worse than the physical ones, most of t he behavior problems with the dementia/alzheimers residents stem from fear, if they call for assist a lot they are afraid or just plain lonely; the main problem i see in this field at this time are the young employees who see them as children not adults; we always say yes mrs. -- or mr. --' they have earned our respect and should receive it at all times; besides, we work for them, not the other way around. THe most difficult part of my job is teaching the young employees that "we work in the residents home"

I would love to work in your country. Sounds grand.Or I may just move there when I need to go into a nursing home. Keep up the good work.!!!

NurseWiggins · Apr 13, 2005

I think its silly. Granted it has some advantages, but there are a few residents at our facitily that constantly fall due to alz/dementia...They place the chair/bed alarms on the residents, but incidents still occur. Then, placed in a merri walker they are falling over in them.....UGGH! Your left with no choice but to "babysit" 1:1 care with these residents, medicate, or write up an accident report along with sending to ER usually for injuries.

I dont like having my residents restraint free...even a lap buddy would help...and yet, they cant be used if the resident isnt able to release the belt. ???? So these residents continue to fall until eventually breaking a hip...Very sad. Protecting a resident isnt as important as slapping a label on the facility "RESTRAINT FREE". ugggh. :devil:

studious · Apr 13, 2005

I think its silly. Granted it has some advantages, but there are a few residents at our facitily that constantly fall due to alz/dementia...They place the chair/bed alarms on the residents, but incidents still occur. Then, placed in a merri walker they are falling over in them.....UGGH! Your left with no choice but to "babysit" 1:1 care with these residents, medicate, or write up an accident report along with sending to ER usually for injuries.
I dont like having my residents restraint free...even a lap buddy would help...and yet, they cant be used if the resident isnt able to release the belt. ???? So these residents continue to fall until eventually breaking a hip...Very sad. Protecting a resident isnt as important as slapping a label on the facility "RESTRAINT FREE". ugggh.

Hi NurseWiggins,

I soooooooooo know what you are saying, it can be really upsetting when a resident or patient falls and hurts themselves. It's even worse when you're short staffed, and have a lot of things happening on the floor. Trust me I know, everywhere is short staffed including where I work.

However, I also know that restraints often go on patients because of the above, not enough staff, 1-1 nursing required, more paperwork etc: I'm not suggesting that your facility does this, so please don't misread me. I'm only suggesting that other options are available i.e safe hips, beds that can be mechanically wound down to the floor, regular reviews of medications, education for staff members. We have several individuals who walk around who have dementia/alzheimers, who are only on the likes of paracetamol, or drugs to help with constipation. Are they at risk of falling? Absolutely, but if in their own minds they feel they have to be somewhere or need to do something, who are we to stop them. Our wee Molly(not patients real name), likes to dust(with imaginary dusters), and is always worrying that the supper won't be ready for her husband coming in from work. In order to alleviate her fears we have an occupational therapist who comes in for a few hrs per week, to help wee Molly bake some cakes(for husband, who died a few years back). This keeps her happy for a little while and helps to alleviate her fears and worries.

It's hard to change an institution, but there are ways of doing it. By all means we are not perfect, and do get things wrong. The main thing is though we are trying to make a better life for people who don't have a lot of time left. I still feel it's better than living in a drug induced haze. Now, it may be prudent to suggest to your bosses that if they want a restraint free environment, what are they going to provide as far as extra equipment, staff i.e physio, Occupational therapists, a standardised letter for relatives stating reasons for non-restraint(taking away dignity and quality of life). I know first hand that bosses can shout the orders and expect the floor nurse to get on with it, some of them haven't a clue what goes on. They sit behind the desk with the pen and paper, get paid a hell of a lot more than we do etc: There are still places over here in the Uk that restrain as well, so it's not all roses.

I'm only talking one small change at a time, if the change is organised well, and the staff are educated appropriately, it can happen. Took us ten years to get things the way they are right now, and we are still looking for ways to improve the quality of life for our patients. Word of mouth has got us with the longest waiting list within our Trust of several hospitals. It's scary to step outside comfy and cosy, routine, institutionalisation. However, at the end of the day I feel we are there for them, they are not there to do our bidding. So what we want and what we would prefer shouldn't be an issue. Rope the family in, friends, get them on side, explain there may be a few injuries, falls etc: but do it in such a way as to promote the individual patients right to live the rest of their life with dignity and as much independance and choice in the care they receive. It's all about partnership, and working together.

It's worth it to see wee Molly with her plate of cakes and a smile on her face.