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.
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 …)
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 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.
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 comments:
Post a Comment