Should I have left pt's restraints on?

Nascar nurse, ASN, RN · Jul 15, 2012

I'm in LTC and have very different regs than you so I can't offer much advice but NO, you don't "self report to the BON". You are obligated to follow physician orders, so in that respect you made an error but this is FAR from the end of the world. (In my world it would be horrifying to even have those restraints or all 4 bed rails up without a very darn good reason).

supaswtchic · Jul 15, 2012

I have never worked at a ltac facility, only at a hospital. Our hospital really pushes for us to not use restraints. We are to use them only as a last measure due to the risks with using restraints. Yes we still use them. Some pt's may have a 1:1 sitter and still be in restraints. What is the pt had gotten tangled and fell. You would still be filling out incident report and feeling guilty. It sounds like you did a good job checking on the pt and reorienting them but unfortunately that one short time span resulted in a fall. It takes a lot more effort to work with the pt so they don't have to be jn restraints. Some of the best nurses I know have had pts who fell. Management doesnt always see our efforts, they just see it as a fall. We try our best but we are just pulled in so many directions we cannot keep all falls from occurring. We have to get an order to use restraints but the nurse can terminate the restraints if she feels best such as when tubes/lines are removed. Do you guys have bed alarms? They have cut down on many falls from occurring at our facility. Don't feel bad just learn from this experience.

Long Term Care Columnist / Guide · Jul 15, 2012

The patient shouldn't have been in restraints at all if the NG and Foley tubes had been pulled and he otherwise wasn't a danger to himself or others. Confusion and agitation are no longer sufficient criteria for restraint use; not only that, but acute care patients are supposed to be reviewed at least every 8 hours to determine the need for continuing use of any restraint, even when they do meet the criteria. Sounds to me like the OP made a good judgment call, even if the pt did fall and hurt himself later. It could've been a lot worse if he'd had restraints on.

BTW, what is an "enclosed" bed??

wanderlust99 · Jul 15, 2012

I use a bed alarm on pretty much every patient now.

It sounds inappropriate to use restraints on a cooperative patient with no lines or tubes to pull. So it sounds like you were using good judgement by removing them. Even if the patient was attempting to get OOB all day, a posey vest would be the better option than wrist restraints, or just a bed alarm would be good. Whoever removes restraints should document when they are removed, and then get the order discontinued. I've worked at many places, and a lot of times we can get it discontinued "per protocol", so we don't need to call anyone.

Unfortunetely patients do fall (rarely we hope), but it does happen. Don't feel bad, and no you aren't supposed to report yourself to the board for this.

kentke · Jul 15, 2012

Hi I am a new RN grad and have worked for 3 months in a LTAC/Rehab hospital. Yesterday I recieved report from day nurse on a new pt that had soft wrist restraints and mittens on because they were pulling out the NG tube and Foley, well the MD signed an order to d/c the NG tube and foley, which I did. The day nurse also told me that pt was able to take off the restraints and they were a "houdini" to really watch them. When I did pt. rounding pt was asleep with restraints on. The day time RN said the pt. had been compliant with all requests and suggested we take the restraints off because the tubing had been d/c. The pt. had a brain injury was confused but cooperative, I educated pt. that I would take the restraints off if he would use the call light, and not get out bed w/out help. Pt was compliant the entire shift (8hour), did not get out of bed (all 4 side rails were up still), took meds no problem, used call light 3x. 10 minutes into PM shift change, we were 6 ft from pts room (door open) we observed pt at doorway and then pt fell and hit head causing laceration above eye, treated with pressure dressing, MD notified along with family and Central Nursing supervisor. MD ordered an enclosed bed for pt. Here is my problem, pt. had orders for restraints, day time nurse did not document that pt was able to take off restraints, if fact they did not document anything in nursing notes other than checking boxes. I documented end of shift what happened, and that day time nurse advised pt able to take off restraints. I removed restraints based on 2 pieces of info, 1st. pt compliant entire shift, and based on verbal report (although RN did not document anything) that pt. can remove restraints. I am angry at myself because I did not see the restraint order (we don't have electronic charting) until end of shift when Charge RN showed me in pt's chart. I filled out a inicident report just like I saw it, I even talked with my Tech who checked on pt 15 mins prior to incident and pt was still in bed and compliant with directions. I feel horrible, angry, and feel incompetent, I don't know if I made a bad decision with leaving the restraints off. If they were left on and pt was able to get out of bed with all straps around him, I felt that injury could be worse. I personally did not see pt take off own restraints. Do I self report to Board of Nursing, is this negligence? Thanks for your help.

Thank you for your feedback, an enclosed bed is a tent bed, the MD. ordered it after pt fell, found out today the pt pulled IV lines, but otherwise pt was ok and was visiting family and were not angry. It was my day off but could not sleep well, still angry at myself, but definately glad pt was ok. I know nursing judgement takes time and does not come overnight, so I know that I have learned from this, I checked the BON and could not really find anything where I would fit "negligence" because the situation was a 50/50...and I would of had a duty to act since I already knew pt could get out of restraints from AM shift report, even though pt was still restrained. The enclosed bed gives the chance for pt to move around without falling out. I will find out Monday if anything further gets reported.

Bec7074 · Jul 15, 2012

I'm sure it's been said, but bed alarm is one thing I see missing here. Where I work (ICU) restraints are common and the docs trust us to put them on and off as we feel necessary. In our order set, we have criteria the pt must meet in order to take them off. It sounds like your pt met that criteria. A bed alarm and mitts may have still been warranted, however. I trust no one, and that's something you will learn with time. All my pts get bed alarms and vented pt's always get restrained even if they are supposedly with it. You never know when someone will wake up suddenly and forget where they are or get loopy from meds. I don't think anything you've said would require attn from the BON.

xoemmylouox, ASN, RN · Jul 15, 2012

The enclosed beds that I have used work great for those who a huge risk for falls, but you don't think other restraints will keep them safe. It gets tough when you have to clean beds. They get messy quickly especially if the patient is in them 24/7. I used one in an LTAC as well.

Long Term Care Columnist / Guide · Jul 16, 2012

I've never seen one. Sounds like a crib for adults. It must be horrible for someone who's claustrophobic!

mom2cka · Jul 18, 2012

Our policy is to discontinue the use of a restraint once the patient's actions no longer warrant this, even if it's only for a short time. We release the restraint every hour, do ROM, etc. All patients in restraints would have 1:1 staff as well. After removing, I'd still use a 1:1, at least over the next shift, and the bed alarm... the head injury patients are tough. You can think they're doing great, and suddenly -they bolt for the door.

0402 · Jul 18, 2012

Soft restraints are not intended to keep a pt in bed; they are there to keep a pt from interfering with medical equipment. (one of my first shifts at my current job, I got into an argument with the charge nurse because she wanted me to put a pt in restraints bc she was getting out of bed, but I refused. To me, there was more potential for injury with the restraints, given that she could physically get out of bed but was very confused than there would be with the bed alarm and everyone aware of the situation- she was already next to the nurses station) I am not a fan of them and would much rather have a pt in mittens, to keep them from pulling things out, but not have them tied down in any way. If the pt is a fall risk, interventions are a bed alarm, increased rounding, room closer to the nurses station, ensuring the pt has what he needs within reach, frequent toileting, etc- not restraints. I have seen an enclosed bed used with a TBI pt in a rehab setting before, but I am not totally familiar with them; personally I would try a bed alarm first. You said the pt was standing in the doorway, not that he fell out of the bed, so the tent doesn't make a lot of sense to me.

As far as removing the restraints, I would agree with what you did. If the pt is compliant and was not pulling at lines during an entire shift, where would the justification be to keep them in restraints. We have to document every 2 hours when we have pts in restraints (I work m/s), and we have to put why we still have them on.