Jonathan Rosenfeld's Nursing Homes Abuse Blog : Jonathan Rosenfeld's Nursing Homes Abuse Blog | Lawyer & Attorney : Strellis & Field Law Firm | Bed Sores, Senior Neglect, Elder Abuse, Sexual Abuse: Chicago, Illinois

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

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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.

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A coroner determined that a 77-year-old nursing home resident choked to death on his dinner, according to an Australian newspaper. The victim suffered from advanced dementia necessitating assistance with meals. Investigators determined that the nursing home attendant assigned to supervise him left the man unattended as he was eating his dinner.

The link to the full article is here.

Choking injuries and asphyxiation are real dangers amongst the elderly. Many nursing home residents suffer from dementia, impaired judgment, difficulty swallowing, and problems chewing food. It is the responsibility of the nursing home staff to identify those who may be at risk for choking.

If a nursing home resident has difficulty swallowing, the nursing home staff should provide soft foods, cut all food into small pieces and make sure the resident is in an upright position while eating. Most importantly, the nursing home staff must carefully monitor residents during mealtimes to prevent choking. Choking incidents may result in injury, medical complications and even death.

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Bedrails are the most common type of physical restraint used in nursing homes today.  Bedrails were once only associated with confining residents to their bed.  Today, new bedrail designs, have been developed in order to assist residents get into and out of bed. 

Even with new designs, bedrails commonly cause falls and entrapment, which may result in fractures or even death.  In order to help identify potential problems with bedrails, the FDA has identified seven 'entrapment zones.'  The most common reasons, residents attempt to leave their beds are as follows:

• Agitation
• Delirium
• Need to use bathroom
• Pain / discomfort
• Hunger / thirst
• Sleep walking
• Difficultly breathing while lying down
• Boredom

Nursing home residents with cognitive impairment are the most likely group to be injured in an incident involving bedrails.  Nonetheless, a complete collaboration with many different departments within a nursing home is imperative in order to provide a safe and restful nights sleep for all.  Simple programs such as: implementation of scheduled toileting, administration of increased pain medication prior to bed and identification of residents with delirium can be helpful in preventing bedrail injuries.

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