Nursing Homes Abuse Blog - By Jonathan Rosenfeld

When you consider forms of cruel treatment, maybe you consider beds of nails or solitary confinement? However, another form of cruel treatment-- the use of restraints, is commonly used with innocent nursing home patients. At some facilities, patient restraints are a commonly used tool used by facilities in lieu of providing actual hands-on patient care by facility staff.

In the past, nursing homes used physical restraints such as: bed rails, lap belts, vests, wrist ties and special chairs to assist them in literally controlling their patients.  In addition to de-humanizing patients, the use of restraints was attributed to rapid physical deterioration and increased rates of patient injury.

In response the the poor publicity and family outrage, many skilled nursing facilities have made great efforts to reduce use of restraints.  The reduction in restraint usage was recently discussed in an article by Megan Brooks on Medscape.

Ms. Brook's article analyzed data from a News and Numbers report from the Agency for Quality Improvement and Patient Safety (AHRQ), which was part of a 2009 National Healthcare Disparities Report.  In short the reduction in use of restraints seems promising-- from 1999 to 2007, the number of nursing home patients who were restrained dropped more than 50%.  

By most estimates, just 5% of nursing home patients are restrained by facilities. Restraint usage varies significantly based on the following factors such as ethnicity, age and sex.  

Certainly this is promising news for nursing home patients in general.  However, the data contained in the AHRQ report does not contain enough specifics regarding nursing home patient demographics to assess if restraints are being improperly utilized. 

To restrain or not?

This really is a very difficult question to answer and the answer varies significantly amongst experts.  I feel restraints may be justified when the patient is at risk for harming themselves or others. 

In my experience, I have witnessed facilities slow to utilize restraints--- even after repeated episodes of falls.  In one of my cases, the facility refused to restrain a patient despite fourteen reported falls (many with associated injuries) at the facility. Unfortunately, the patient's fifteenth fall resulted in a head injury which ultimately cost the patient her life.  In the course of litigation, I asked the director of nursing why the patient was not restrained, she advised that the facility was a 'no restraint facility'.

In this case, I think there certainly is a very strong argument that I can (and will make) that with a no restraint policy, the facility was not properly equipped to care for this patient due to her extensive history of falls.

In another restraint case I worked on, a patient was seriously injured when she was left unattended in her geri-chair with an improperly placed lap belt.  Apparently, the belt was too loose and when the woman slipped down in her chair, she became entangled and choked.  Again, in the course of litigation, the facility disclosed that lap belts were used on all patients --- regardless of their physical abilities.

Certainly, regardless of a facilities restraint usage policy, it is up to the facility adequately supervise patients to ensure the usage / non-usage of restraints doesn't interfere with the patients well being. Further, this is an important issue for families to discuss and know where the facility caring for their loved ones stands on this issue.

Related Nursing Homes Abuse Blog Entries:

Many Nursing Homes & Assisted Living Facilities Continue To Threaten The Safety Of Their Patients With The Use Of Bed Rails In Their Facilities

Warnings Do Little To Prevent Bed Rail Entrapment 

Bedrail Entrapment

Can a nursing home tie my dad to a wheelchair if he has had episodes of wandering around the facility?

More than 20 years after Congress passed the the 1987 nursing home regulatory law (OBRA) which granted nursing home residents the "right to be free" restraints for discipline or staff convenience--much progress needs to be made to accomplish that goal.

Once widely thought to prevent nursing home residents from falling and wandering off, the use of physical restraints is not nearly as common in most nursing homes. According to a recent USA Today article, the use of physical restraints amongst nursing home residents has been drastically reduced over the past 20 years.  Medicare statistics verify 21.1% of residents were restrained on a daily basis in 1991 compared to just 5.5% in 2007, the most recent full-year set of statistics available. 

'Restraints' are generally known as any device used to prevent a resident from wandering or falling, or residents who may be easily agitated (due to uncontrolled pain).  The most commonly used restraints used in the nursing home setting are bed rails and geri-chairs. However, nursing homes have been be known to use make-shift 'tie downs' thereby securing residents to beds, benches, dining chairs and even toilets.

While the use of restraints may seem like a way of controlling a resident from harm themselves, studies have shown that restraint usage causes muscles to atrophy and result in residents actually becoming reliant upon the restraints for support when sitting or walking.  The psychological consequences of restraints are also a problem encountered in nursing homes.  According to Dianne Snyder, of Thornwald Home--  a restraint-free nursing home in Pennsylvania, "They experience some anguish.  You kind of break their spirit.  They give up."

Situations involving injury or death with the use of restraints are more common than most would like to believe.  If a resident is left unattended with restraints in place, they can become tangled in straps resulting in strangulation or broken limb.

Is it possible to ban the use of restraints in nursing homes?

There will always be residents are some facilities who require the use of physical restraints to protect them from harming themselves.  However, there is ample room for further reduction.  For example, Pennsylvania a voluntary program to ban the use of restraints of which more than 90% of the state's nursing homes participate, has reduced the use of restraints to just 2.8% of residents last year.

Like everything in the nursing home, the quality of care provided to residents is a reflection of the training provided to the staff.  Staff intervention is essential to identify those who may be predisposed to falling or wandering from the facility.  Fall prevention techniques such as: padded floors, non-slip chairs, adjustable beds and socks with traction may quickly reduce the number of residents who require the use of restraints.  Nursing homes must "educate, educate, educate" according to Snyder. "Not only the staff, but also residents, families and physicians."

Related Nursing Home Abuse Blog Posts On Restraints

Warnings Do Little To Prevent Bed Rail Entrapment

How Much Freedom Should Assisted Living Facilities Give The Mentally Disabled?

Web Resources On Restraints

Report: "Freedom from Unnecessary Physical Restraints: Two Decades of National Progress in Nursing Home Care" 

SAFETY WITHOUT RESTRAINTS, A New Practice Standard for Safe Care, Minnesota Department of Health

Despite long standing warnings from the FDA, bed rail entrapment continues to be a real threat to the safety of people in nursing homes, hospitals, and long-term care facilities.  After FDA warnings were issued on rail safety, many manufacturers began production of safer designs.  Although the warnings have been issued, the FDA has not imposed any bed rail recalls on beds known to commonly be the source of injury and death.  The lack of formal action by the FDA will likely result in future incidents involving: injury, fractured bones, strangulation, asphyxiation and death.

The safer rail designs have yet to make there way to the places they are needed.  At many facilities there is little incentive to discard a usable bed, despite the fact that the design may be antiquated and unsafe.  Further, many beds are rented from medical supply companies that have a substantial inventory of beds with older designs. 

Rental beds are typically the least safe beds in use today.  Many rental companies pay little attention to the combination of parts used when distributing beds for home and facility use.  It is common to see a mattress designed for one bed used with the frame from a different manufacturer.  The combination of mattresses and bed frames results in unintended 'gaps' in which a person can easily get caught.

In 1985 the FDA issued a Safety Alert on the dangers of entrapment in bed rails, and other parts of hospital and nursing home beds.  The alert was directed to home healthcare agencies, hospices, and nursing homes.  The FDA based the alert on its published reports documenting deaths and injuries associated with beds and bed rails.

By 1999, bed safety had become such an important issue, the Hospital Bed Safety Workgroup (HBSW) was assembled by the FDA, the medical bed industry, national healthcare organizations, patient advocacy groups and other federal agencies. After years of debate, the HBSW produced a brochure, which provides guidance for selecting a bed and instructions on how to measure for dangerous gaps between the mattress and bed rails.

Lightweight patients are generally at the greatest risk for bed rail entrapment.   Smaller people are more likely to fall into gaps between the mattress and the bed frame.  Other factors in determining a persons susceptibility of bed rail injury are: their mobility, agitation and temporary or chronic reduced mental capacity.  Patients with the above conditions require ongoing monitoring from the staff in order to reduce their risk of harm.

In order to minimize the risk of bed rail injury you should examine the bed and mattress to make sure the mattress 'fits' with the frame.  If you see gaps between the frame and the mattress, you should point out the situation to the facility.  Lastly, ask questions.  Do not be afraid to ask the nursing home or long-term care facility about the type of beds they use and if they have had any problems with the bed before.

For additional information on bed rail safety, review Professor William Hyman's article appearing on McKnight's website here.

According to the FDA, there are more than 2.5 million hospital and nursing home beds in use in the United States.  Between 1985 and 2008, there were 772 incidents of where nursing home residents were caught, trapped, entangled, or strangled by bedrails.  Of the above incidents, there were 460 deaths.  Most of the injured individuals were elderly in weakened physical and emotional conditions.

Currently, I am are representing a 77 year old woman who became entangled in a bedrail while attempting to locate the 'call button' in her room.  The woman sustained a fractured ulna and radius to her arm which necessitated open reduction / external fixation.

For the FDA Guide To Bed Safety Bed Rails In Hospitals Nursing Home and Health Care: The Facts, click here.