Chemical Restraints
Researching how to keep Margaret in her wheelchair now that she is again active landed me in the area of mechanical restraints. It is followed by chemical restraint. We know what that means.
We spent a couple of months In skilled-nursing, in the nursing home my mother stayed at over 20 years ago, while our apartment area was rebuilt after a flood. Xanax was administered to keep Margaret “calm” by the house doctor’s order. We first saw a frightening chance in her personality (she sort of disappeared) followed by six falls as she slowly adjusted to the dosage two years ago. https://residentialcarefortwo.blogspot.com/2017/02/fall-number-six.html
This past year Xanax has been continued on a PRN basis at a minimal dosage. It then increased. Is the current dosage a chemical restraint? Memory care substitutes time to redirect and distract in place of using “calming” medications.
The first two of seven purchases were for one pill a day to be used as needed. The other five were for two pills per day and/or as needed.
Factoring in the time each purchase lasted yields the average number of pills per day. The facility never used the maximum rate the doctor ordered of two pills per day for the entire lot of 30 or 60 pills.
Medical records would show why the dosage was changed from one to two pills; and in spite of this, the average dosage was about the same for the first and last purchases.
During the time of maximum use, Margaret had three falls that took her to the emergency room. The regulations require massive documentation to determine if the usage was for a medical condition or for the convenience of under trained and inexperienced caregivers. Our insurance company sent us a note at the first of the year cautioning us about the use of Xanax for elderly persons.
- Whether an excessive dose and/or duration of the medication was administered to the resident;
- Whether there is adequate monitoring for the effectiveness of the medication in treating the specific condition and for any adverse consequences resulting from the medication; . . .
Risks and Psychosocial Impacts Related to Use of Chemical Restraints A medication that is used for discipline or convenience and is not required to treat medical symptoms, may cause the resident to be: [We experienced this in our two months in skilled nursing.]
- Subdued, sedated, or withdrawn; [One pupil much larger than the other.]
- Asleep during hours that he/she would not ordinarily be asleep; or
- Limited in his/her functional capacity. [A blank face with a stare into the distance.] . . .
Additional effects . . .
- Decline in physical functioning including an increased dependence in activities of daily living (e.g., ability to walk), impaired muscle strength and balance, decline in range of motion, and risk for development contractures, increased risk of falls; and . . .
(p 125) Facilities are responsible for knowing the effects medications have on their residents. Even if a medication was initially administered for a medical symptom, the continued administration of a medication in the absence of a medical symptom, that sedates a resident or otherwise makes it easier to care for them, is a chemical restraint. Other examples . . .
- Staff have recommended to the practitioner that a resident be administered a medication in order to prevent a resident from displaying behaviors . . .
- Staff become upset with a resident who resists receiving a bath and pinches staff. [Or hits with some strength going into the shower. A San Antonio 16-bed facility had no apartment showers; only a well heated showerroom the residents liked to use.]
(p 127) Interview direct care staff and/or licensed personnel (e.g., nursing, social workers), as appropriate, on various shifts that provide care to the resident to determine: (7 of 11)
- Why the medication is being administered and what effect (physical and/or psychosocial) it has on the resident; . . .
- · Depending on whether distressed behavior is expressed, how do staff respond and what individualized, person-centered interventions are attempted; . . .
- [Pacing the “1, 2, 3, Stand” count to Margaret’s body language. Stand comes at the point where she is willing and ready to stand (0 seconds to 5 minutes).]
- [Strong hits are referred to as “Love taps.”]
- [Avoid any negative statement or comment that suggests that Margaret will be prepared to respond in kind. ]
- [Ask questions in our apartment, and of others, after being absent several days.]
- [Leave on toilet long enough to be effective (5 to 15 minutes (work on something else and come back).] [Margaret is classified as a “two-person assist resident” for the protection of her and her caregivers based on her weight.]
- [Either put her to bed by 8:00 pm or get her ready any time after the evening meal and then let her watch TV so she is not overly tired when changing for bed.]
- Who and how the facility monitors for adverse consequences related to the administration of the medication; . . .
- How is it determined that the medical symptom is no longer present and who determines this; . . . [A PRN time-limited basis may or may not be a restraint.]
- How staff are assigned to monitor, care for, and be familiar with residents’ behaviors (e.g., the number, location, and consistency of staff assigned across different shifts/units); . . . [Rate of rotation of staff among three assisted living floors and two memory care floors.]
- Who supervises the overall delivery of care to the residents to assure care planned interventions are implemented and supervision occurs (to assure that a chemical restraint is not being used for staff convenience); and
- Whether staff have discussed concerns with the Director of Nurses and Administrator regarding the behavioral symptoms of specific residents and the monitoring of intervention, and whether staff have requested more resources or changes to resident assignments, and the response to the concerns.
With all of the above in mind, the use of Xanax can be examined. Originally this post was scheduled for after the first year of medication: How do family members monitor the use of drugs independently from the facility records. The misuse of drugs has been a common practice in long term care. Provision Living contracted with a bubble pack supplier who both delivers the medications and monitors daily use over the Internet (for about $600 per year for us, but we were not accepted).
Our stay in skilled-nursing was another learning experience about what I would now call a chemical restraint. In two weeks we will meet with our neurologist to review “calming drugs” used for the past year and the state of her hands after her concussion last summer.
The year started with a letter from our health insurance HMO warning us about the risk of falling with use of Xanax in elderly people. I was assured that this was not a problem as it was being used at the minimum dosage and on an as needed basis. The chart shows the dosage was doubled after the first month. Currently the dosage is one pill AM and PM, and another as needed.
To my knowledge, until several of the above questions are answered, there is no way to know if current use represents a restraint or a non-restraint. Or at times it is one or the other?
What we do know is that Margaret has become active this week to the point everyone is commenting about the “old days” before the concussion. This creates problems. She is now falling (sliding) out of stuffed chairs as well as out of the wheelchair.
She is permitted to have the wheelchair brakes unlocked when I am in the dining and activity area to watch her. She can move about at the table and return without someone pushing her back in place every few minutes with the brakes locked (restrained). She is free to roam again (by walking the wheelchair, as she cannot use her hands); when she is not being restrained in front of the wall TV screen. [Rumor has it that the new owners are hiring a new memory care director of activities.]
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