Wheelchair Restraints

The use of lap belts, at the hip level, is mired in several lines of mushy statistics. Once laws were passed regulating restraints  (mechanical and drug), they created a playing field for residents, relatives, doctors, lawyers, administrators, directors at all levels, and the caregivers who actually care for patients, and in addition, live with and interact with memory care residents (that portion of assisted living behind the locked door).

This same mix is found in professional, college, and high school sports. The rules for the “big game” are different at each level and for each sport. They all have referees, taking part IN the game (not scattered in isolated offices). All the players are reasonably competent to accept the risks of playing. They have the choice to play and not to play within the family and regional politics.

 A memory care resident is not competent to do some things but is deemed competent to “refuse medication” and other things that would require additional time to perform under the circumstances. This law makes it acceptable to not deliver what a doctor has ordered and relieves any liability for not delivering. It allows things to go as planned for a patient in skilled nursing rather than taking the time to meet the residents needs in memory care. 

[We actually experienced this (a drug restraint) when an overdose, in my judgment, was given to Margaret in a skilled-nursing setting to keep her in line even though it caused her to fall six times every other day. The house doctor was then overruled by memory care rules until we returned from the flood.]

The passion to eliminate all restraints produced legislation as the 1987 Nursing Home Reform Act. It is a political policy statement. It is not a set of operational rules. It must be interpreted by the “referees” at all levels. The fear of lawsuits plays as strong a role, at one end of the spectrum of players, as the best care for each patient or resident, at the other end.

Free from Restraints.—The right to be free from physical or mental abuse, corporal punishment, involuntary seclusion, and any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident’s medical symptoms.

This reduced the use of restraints in nursing homes from 21% to 5% in 17 years in the USA!

   Restraints may only be imposed---(i) to ensure the physical safety of the resident or other residents, and (ii) only upon the written order of a physician that specifies the duration and circumstances under which the restraints are to be used (except in emergency circumstances …)

 Physicians now have control of what and when restraints are to be used. But caregivers must be trained to effectively and safely carry out the orders. 

This is good legislation. But it took place during a time when a transfer took 1/3 of a minute for a large man to lift a 200 pound patient, to a time now where it takes a 130 pound person 3 minutes to direct and assist a 200 pound resident to stand up and make the transfer. That change from working with a commodity to interacting with a person took many years. I see this take place in a few weeks as new hires discover, “Oh, she walks.” And “Oh, she can stand up.” The trade of a few minutes to not have to lift 200 pounds makes a big difference in back strain and the number of needed caregivers.

By 2008 the Centers for Medicare & Medicaid Services (CMS) had formulated an operational definition of a restraint in addition to “it promotes looking at each patient situation on a case-by-case basis”.

In addition, if a patient can easily remove a device, the device would not be considered a restraint. In this case, “easily remove” means that the manual method, device, material, or equipment can be removed intentionally by the patient in the same manner as it was applied by the staff (e.g., side rails are put down, not climbed over; buckles are intentionally unbuckled; ties or knots are intentionally untied; etc.) considering the patient’s physical condition and ability to accomplish the objective (e.g., transfer to a chair, get to the bathroom in time).

 We now know that Margaret is again active, cruising the halls and activity areas, and interested in the two shelves of keepsakes in our apartment. We know how she fell from chairs in our apartment when she turned and overreached. We know what happened on her first excursion into our apartment in her wheelchair earlier this week. (Please see previous post.)

We also know that some places just band all wheelchair lap belts on the basis of a general policy that the risk of using them is higher than the assumed risk of falls onto the floor. [One serious restraint accident is valued the same as 20 average falls on the floor. The falls are not accidents as they are expected. But one of the falls may be more serious than the restraint accident.] I would agree with the ban when working with incompetent caregivers who do not know their charges and do not provide the appropriate monitoring. When we can expect repeated falls, there is need for corrective action: a lap belt at the hip level, that easily opens when needed to be released.

My understanding then is we can use the lap belt to provide Margaret the freedom to roam and enjoy herself. Walking the wheelchair is good exercise. Perhaps she may even get back to using her walker that ended with the concussion. Or learn to use both hands again.

A caregiver will need to monitor her seating position. Unless she becomes active in reaching for things, this should not be a problem. When she is active, she can slide to the front ½ of the chair in 10 to 15 minutes without a lap belt. 

However, there may come a time when she cannot release the lap belt. In that state of health see is doomed to hit the floor unless she is carefully monitored without a lap belt. That same monitoring with a lap belt would seem to be a more reasonable choice.

 

Fall Prevention by kdsmartchair.com

At this point we are again operating on passion (for an individual; not for a statistical average) and on accurate assessments of actual risks (which for me are mostly unknown).  “Avoid leaning forward --- Don’t over reach --- Avoid sliding … too far forward” refer to skills that must be learned (and remembered). Memory care residents do not learn or remember. A lap belt does not forget. Will she be safe, in the spring, on the endless walk in the memory care patio area?

At present, falling from a wheelchair has progressed to the same point as refusing medication. They are both defined as acceptable in the industry and therefore rarely subject to litigation. 

The risk from using a lap belt is related to the environment in which it is used. I would consider it a necessity when Margaret is actively working with her keepsakes in our apartment. Or the emergency call system responds within 5 minutes about every half hour.  Or we could just dispose of the keepsakes. She refuses to have the TV on in our apartment, as was the case in our house, but she can watch TV, in her wheelchair or another chair, for hours in the activity area.

No Wheelchair Lap Belt

Yesterday was a thriller. One of the two new hires that Margaret took a liking to on sight came to the open door of our apartment and told me, “Margaret is on her way.” 

Sure enough. She was just one door away walking her wheelchair. In she came. I opened two shelves on the bookcase with her keepsakes. She immediately started picking up things and rearranging them. 

Moving Foreward 

She turned to work on the other set of selves opposite the bookshelf. I then noticed she was riding about ¼ of the way from the back of the wheelchair seat. I took a picture to post on Facebook. It has been four months since she was acting normal. I posted the picture.

On the Unknown Brink

Then, she was riding about ½ way from the back of the wheelchair seat. Another picture. Another post. This did not look good. I pulled the “emergency” cord. 7:17 PM.

With her attention focused on keepsakes there was no way for me to direct her to stand enough to reseat her in the wheelchair. 7:22 PM. She was still secure in the wheelchair.

7:25 PM. As she reached out full length with a slight turn to the left, the wheelchair backed away ever so little letting her settle onto the floor. The front edge of the seat was caved toward the back of the wheelchair. The entire seat was bowed down. She had been ejected. She did not fall.

The tipping point is not on the front edge but ½ way from the back; if she turns in the seat. A lap belt could prevent this. So ended her first time in our apartment under her own steam since the concussion. 

 I have argued the need for a lap belt for months. “Missouri law does not allow restraining residents.” “But she is falling almost weekly.” [I have one on order now as I have not found one in Columbia.] [[It is here but without the expected red button.]]

We now know she has not been “falling”. Her bruises are consistent with sliding out of the chair, not hitting the floor when felling.

7:30 PM. I walk into the hall and call to a caregiver I happen to see in the activity area, a city block away.  What to do? There is no room for three small caregivers to pick Margaret up. “Get N___.” He comes. Margaret is up and into the wheelchair again.

Our apartment alarm did not sound in the nurse office in memory care one. No receiver sounded in memory care one. I checked with memory care two. Often the alarm can sound on the wrong floor. The caregivers see this and use their “walkies” to alert the correct floor. 

The main nursing office has a monitor of the Provision Living Wireless Emergency System. Among other things, it detects which pull cord and pendent units have low batteries or are just not working. This is only operational if someone is looking at it and sees repeated calls and that low batteries are changed (a half time job for over a week) . 

From my experience, and that of several caregivers, the system can work if each caregiver has a receiver. It is turned on. It has a good battery. It is not left somewhere while working with a resident. There is then no need to make a cell phone call to the concierge (who is no longer on duty after 10:00 pm).   

[To staff the building as it was designed would require more people with the possible restoration of services offered during startup.. As is, one of these offices is now used to store incontinence wear in memory care one where it is used.]

You are teasing me again.

Margaret seems totally unaware of this commotion. Yesterday and today she has been a different person than during the past four months. I even got a photo to prove it. The attention she gets from her daily occupational therapy on the fingers on her right hand may be a factor here.

Video Clip Monitoring

This morning at 8:00 three of us confirmed that Margaret’s two rashes were not only over, but her skin had returned to normal color and texture. The Arlo video clip camera helped in sorting out cause and effect.

It could not monitor what happened outside our apartment but it has established the wide variation in how services are timed that still permitted the total clearing of the yeast and wetness rashes. The toileting schedule, with adequate time, for the afternoon shift wiped out the wetness rash.

The dryness check schedule in the night shift changed the 1:00 and 3:00 checks to 12:00 and 4:00 after 13 December. However once cure and prevention activities were replaced with the normal routine in memory care the result was a mix of the two schedules with no effect on a final cure, or the return, of the yeast rash.

A generalized dryness check schedule is every two hours except for 10:00 pm and 2:00 am. This fits the compromise between 4-hour sleep periods and not being wet for more than four hours.

Incontinence wear is now stored in memory care one. This saves a 5-10 minute trip, to the old supply room, that Arlo caught glimpses of in the past.

The night shift is assigned to see that an adequate supply is in each apartment. That means enough to carry through a bad day for both pull ups for day use and tabbed briefs for the next night. An adequate supply for the building, we just found out last week, must be at least two weeks without any delivery.

The choice was made to use two different items, rather than one convertible item what is shipped as a pull up but can be converted to a tabbed brief, last spring.

We all learned a lot working together on this project. The current tabbed brief can be formed into a pull up, if you know how. Now the tabbed brief can be more easily put on before going to bed. It has a greater capacity for night than the pull up.

[One day later from several caregivers: How to use the tabbed brief is a matter of skill and assessment of the resident's temperament. Skilled caregivers who know Margaret's behavior appear to do this easily. She stands for them. Others struggle. She must be lifted. The tabbed brief does not always fit properly which gets her nightgown wet. The bed pad saves the bedding.]

The Arlo video clip camera has good security. Nothing needs to be downloaded to my computer to get the timing of dryness checks. All clips are deleted after seven days unless I delete them sooner.

I was going to make an exception if only I were in view until last week, On three days I made a dash to the bath with explosive diarrhea and one session of vomiting all over my bed.

Arlo does have a limitation. It needs the Internet. Most of the time it resets but one time it lost a night because it needed to be reset manually. If something moves; Arlo sees it, from blanket dust particles from dryness checks to the far side of the room. Now to find where the monarch caterpillars hide at night next summer.

[The camera may be useful when residents become training aids, with and without, instructors. Many new hires need to develop the rapport needed to invite a resident to assist them and thus make their duties easier and more satisfying to the resident; turning "I am here to do something to you" into "We are going to do something" in a proper memory care or assisted living time frame.]

[This post was written in one day; today. I hope to add photos later.]