State Operations Manual - Physical Restraints

[I have extracted signal sentences from six pages related to restraints used in long term care facilities in Missouri. See previous post for photos of our wheelchair and the decision of using a restraint or other alternatives to keep Margaret from sliding out of the wheelchair. Bolding and underling have been added for quick review.]

483.12(a)(2) When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluations of the need for restraints. (p 110)

DEFINITIONS “Physical restraint” is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria:

•              Is attached or adjacent to the resident’ body;
•              Cannot be removed easily by the resident; and
•              Restricts the resident’s freedom of movement or normal access to his/her body.

“Removes easily” means that the manual method, physical or mechanical device, equipment, or material, can be removed intentionally by the resident in the same manner as it was applied by the staff. (p 111)

Assessment, Care Planning, and Documentation for the Use of a Physical Restraint . . . There must be documentation identifying the medical symptom being treated and an order for the use of the specific type of restraint. However, the practitioner’s order alone (without supporting clinical documentation) is not sufficient to warrant the use of restrictions. The facility is accountable for the process to meet the minimum requirements of the regulation including appropriate assessment, care planning by the interdisciplinary team, and documentation of the medical symptoms and use of the physical restraint for the least amount of time possible and provide ongoing re-evaluation. (p 112)

Also, a resident, or the resident representative, has the right to refuse treatment; however, he/she does not have the right to demand a restraint be used when it is not necessary to treat a medical condition. (p 113)

Facilities are responsible for knowing the effects devices have on its residents.

The use of a restraint must be individualized and be based upon the resident’s condition and medical symptoms that must be treated. While a physical restraint may be used to treat an identified medical symptom for one resident, the use of the same type of restraint may not be appropriate to treat other residents with the same medical symptoms.

. . . for concerns related to ensuring the resident receives adequate supervision to prevent accidents).

NOTE: Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of physical restraint. (p 114)

Reasons for using restraints for staff convenience or discipline may include:

•      . . . too busy to monitor the resident, and their workload includes too many residents to provide monitoring.
•      . . . not enough staff . . .
•      . . . new staff and/or temporary staff do not know the resident, how to approach, and/or how to address behavioral symptoms or care needs . . . [How to slow down, read memory care resident’s body language, and provide the time needed for a resident to respond to well-spaced commands for Margaret.]
•      Lack of staff education . . .
•      In response to a resident’s wandering behavior . . .  [Margaret is free to wander in memory care, but not to open a door to other apartments, in general.]

[Short term understaffing seems to be acceptable: “high activity times.” Failure to plan for this is the problem.] (p 115)

NOTE: . . . For safety reasons, do not request that the resident remove the restraint, but rather, request that staff ask the resident to demonstrate how he/she releases the device without staff providing specific instructions for the removal. . . . Additionally, falls that occur while a person is physically restrained often result in more severe injuries (e.g., strangulation, entrapment. (p 117)

KEY ELEMENTS OF NONCOMPLIANCE To cite deficient practice at F604, the surveyor’s investigation will generally show that the facility has failed, in one or more areas, to do any one or more of the following:

• ·     Ensure that the resident is free from physical restraints imposed for discipline or staff convenience.
• ·     Identify the medical symptom being treated when using a device or a facility practice that meets the definition of physical restraint.
• ·     Define and implement interventions according to standards of practice during the use of a physical restraint that is used for treatment of a medical symptom.
• ·     Provide the least restrictive restraint for the least time possible.
• ·     Providing ongoing monitoring and evaluation for the continued use [and of the current] use of a physical restraint to treat a medical symptom; or
• ·     Develop and implement interventions for reducing or eventually discontinuing the use of the restraint when no longer required to treat a resident’s medical symptoms. (p 118

MY COMMENTS: The wheelchair then turns out to be a hazardous restraint for memory care residents. When I started to get out of the rental wheelchair at the store several people yelled, “Lock the brakes”. 

These rules reflect a concern by the powers that influence long term care to take the doctor and the facility out of range of liability claims when operating with "best practices" in relation to falls. Restraints are not to be used to prevent (occasional) falls. 

At some point a resident can be restricted to use a cane or a walker. At another point the resident is restricted to a wheelchair. Then restricted to a transfer chair. And finally to bed.

As a customary practice they are acceptable. The frequency and number of falls seems to be of importance in making the transitions; with the doctor and facility not liable for acceptable falls. 

All falls cannot be prevented. Excessive falls and accidental falls are to be avoided. Chemical restraints can also increase the rate of falling.