Physical Restraints
The Centers for Medicare & Medicaid Services (CMS) defines a physical restraint as “any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body.” (42 CFR 483.13(a)) When determining whether a device meets the definition of a physical restraint, the focus should be on the effect the device has on the resident, not the intent or reason behind the use of the device. Restraints may only be used to treat the resident’s medical symptoms upon the written order of a physician, except in the case of emergencies. (SOM, 2006)
Types of physical restraints include, but are not limited to leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions, and lap trays the resident cannot remove easily. Also included as restraints are facility practices that meet the definition of a restraint such as:
- Using side rails that keep a resident from voluntarily getting out of bed
- Tucking in or using Velcro to hold a sheet, fabric, or clothing tightly so that a
resident’s movement is restricted - Using devices in conjunction with a chair, such as trays, tables, bars or belts, that
the resident cannot remove easily, that prevent the resident from rising - Placing a resident in a chair that prevents a resident from rising
- Placing a chair or bed so close to a wall that the wall prevents the resident from
rising or voluntarily getting out of bed (SOM, 2006)
The Resident Assessment Instrument (RAI) Manual offers guidance for the review of conditions commonly associated with restraint use:
- Problem Behavioral Symptoms
- Risk of Falls
- Conditions and Treatments (Resistance to Tubes or Mechanical Devices)
- ADL Self-Performance
- Confounding Problems Associated with Behavioral Symptoms (Delirium; Impaired
Cognition; Impaired Communication; Unmet Psychosocial Needs; Sad or Anxious
Mood; Resistance to Treatment, Medication, Nourishment;
The use of restraints not only violates resident’s rights to freedom and dignity, but has also been associated with higher rates of injury and injurious falls, precisely the condition that the restraints are designed to prevent. There are many negative effects and risks associated with restraint use that in some cases far outweigh any possible benefit of using them. Risks associated with using restraints are listed below:
- Strangulation
- Loss of muscle tone
- Decreased bone density (with greater susceptibility for fractures)
- Pressure sores
- Decreased mobility
- Depression
- Agitation
- Loss of dignity
- Incontinence
- Constipation
- Death
(RAI, Appendix C, p. 99)
Some barriers to restraint reduction/elimination include:
- Perception that physical restraints deter disruptive behaviors and wandering
- Perception that physical restraints prevent falls
- Perception that physical restraints are a safety device
Resources
Quality Measures Resource Manual, February 2006, Version 5.0.
Physical Restraints – Available: http://www.medqic.org/Chapter6K
Revised Long-Term Care Resident Assessment Instrument User's Manual, December 2002, Version 2.0, Revised March 2006. Available: http://www.cms.hhs.gov/RAI
Centers for Medicare & Medicaid Services. State Operations Manual, Guidance to Surveyors for Long Term Care Facilities, Appendix PP, Rev. 15, Updated June, 2006.
F221 Physical Restraints (pp 54-60). Available: http://cms.hhs.gov/
U.S. Department of Health and Human Services. Nursing home care improving in many areas new CMS data show, new steps initiated. December 2004. Available: http://www.hhs.gov/news/press/2004pres/20041222.html.
U.S. Department of Health and Human Services. (2001, October) 42 Code of Federal Regulations, Part 483 Subpart B, Requirements for Long Term Care Facilities, U.S. Government Printing Office and National Archives and Records Administration Office.
