Restraints: Use of

Definition:  Merriam-Webster’s online dictionary defines “restraints” to mean the “action of keeping someone or something under control,” or “a measure or condition that keeps someone or something under control or within limits.

Personal Rights:  Restraint of a resident violates a resident’s Personal Rights, Title 22, Section 87572: 

a)    a resident is to be free from corporal or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature. . .” ,

b)   a resident is to be able to leave or depart the facility at any time and not to be locked into any room, building, or on facility premises by day or night.  This does not prohibit the establishment of house rules, such as the locking of doors at night, for the protection or residents; not does it prohibit, with permission of the licensing agency, the barring of windows against intruders.

Many things in an assisted living facility can be used to restrict the movement, motion and activity of residents:  postural supports (braces, soft ties intended to keep a resident upright, casts), bed-rails, geri-chairs, sliding trays, locks on doors, wooden bars in sliding doors, and drugs.

Postural Supports allowed by Title 22 ( Section 87608(a)(1) include “ . . . appliances or devices such as braces, spring release trays, or soft ties . . .used to achieve proper body position and balance, to improve a resident’s mobility and independent functioning, or to position, rather than restrict” a resident’s movement.

Postural supports require a) “quick release” by the resident and b) a written order from a doctor prior to use. 

Postural supports may not be used to tie, limit or deprive a resident of the use of her hands or feet.

Bed-Rails are allowed by Title 22, a postural support under Section 87608(5)(a); they may be used for mobility aids only.  Bed-rails that extend from the “. . .head half the length of the bed, and used only for assistance with mobility shall be allowed.”   Full bed-rails are prohibited except for residents receiving hospice care, with a care plan that specifies the need for full bed-rails.  Bed-rails are not to be used as a restraint to keep a resident in bed during the night, or to facilitate an understaffed facility. 

Geri-chairs with sliding trays:    Geri-chairs are standard in many facilities;  they allow the resident to be positioned in an upright position with the tray pushed close to the body thereby facilitating independent feeding and ease of swallowing.   However, CARR has seen these chairs be misused by laying the person back in the chair to a quasi-supine position incapacitating an individual from getting out of the chair – they are essentially ‘pinned’ into the chair. 

Locked Doors:    At no time may a resident be locked in or locked out of his room.   If a door has a lock on the inside, the lock must be a single-action so the resident can quickly get out. 

Blocked Sliding Doors:   Another form of restraint or restriction of a resident’s movements occurs when the Licensee has blocked the exit door to the outside.   Rooms are approved for non-ambulatory when the room has an exit to the outside, for example: a French door, a sliding door on a track, or a regular door.  CARR has seen documentation where furniture, storage boxes has blocked the exit, or where a stick has been placed in a sliding door track preventing the door from being used as an exit.  Blocked exits are considered a form of restraint.  Blocked exits are also a violation of Title 22, Section 87307(d)(6). 

Psychoactive Drugs:     California Advocates for Nursing Home Reform (CANHR) is a leading advocate of minimizing or eliminating the use of psychoactive drugs on residents of skilled nursing facilities and in residential care facilities for the elderly.  According to CANHR there are four types of psychoactive drugs:  antipsychotics (Zypreza, Haldol); anti-anxiety drugs (Ativan, Valium);  anti-depressants (Prozac and Zoloft);  sedatives and hypnotics (Halcion/Restoril).   The subject of misuse and overuse of these drugs is huge; suffice it to say here that if your resident is taking these drugs,  your resident is susceptible to the drugs being used as a chemical restraint. 

Risks of Restraints:  The risks of a resident being restrained include physical and emotional distress.  Physical manifestation can include decubitus ulcers (bedsores), bruising, incontinence, constipation; emotional manifestations include emotional distress, intimidation, anger, isolation, and loss of personal dignity.  The long-term effects of being on psychoactive drugs are myriad, and in many cases, exacerbate existing medical conditions, hastening death.

Why would a facility use restraints on a resident?    Facilities are frequently understaffed; Title 22, Section 87411 requires that ‘facility personnel shall at all times be sufficient in numbers, . . . and competent to provide services necessary to meet resident needs.”  That said, facilities generally staff lean, therefore it may be to the benefit of the facility to periodically restrain residents, particularly those tending to be wanderers, those who may be disruptive,  or those who may be aggressive. 

Consumers are asked to be ever watchful and vigilant and be on guard for a resident in, or under restraint.  Be watchful not only for your resident, but for others in the facility as well.

Resource:  The Ombudsman Services of Northern California publishes a helpful on-line guide “RCFE Regulation Reference Guide”  http://rcfe.lsnc.net/restraints/ that provides general guidance what is allowed and what isn’t allowed regarding restraint of residents.

Notes in italics represent the views and/or experience of CARR regarding this topic and/or regulation.