Establishing a Facility Restraint Program 

Since OBRA 1987, the use of physical restraints in nursing homes has declined to less than 10% nationally, ranging from 2.7% to 22.4% among the states. According to CMS, restraint use is among the top ten survey citations. 

Numerous studies by the Department of Health and Human Services have demonstrated that the routine use of restraints does not reduce the risk of falls or fall injuries. In fact, the use of restraints can actually contribute to fall-related injuries and deaths. 

Quality improvement organizations are consistent in their emphasis on the importance of establishing and maintaining a facility restraint reduction program. If the facility does not have a program in place, or is seeking to improve the existing program, action can follow the normal steps of the nursing process: Assessment, Planning, Intervention, and Evaluation. 

Assessment

Examination of current:

• Restraint use policies and procedures
• Restraint use practices in the facility
• Restraint assessment and monitoring forms and practices
• Staff, resident, and family knowledge of restraint use alternatives and potential negative outcomes
• Documentation of effectiveness of restraint use practices

Planning

Choosing key staff members to form a Restraints Committee will facilitate the planning process. Members should ideally include, at the minimum, the Director of Nursing and representatives from the Restorative Nursing, MDS 3.0, and Quality Assurance departments. Goals can be set by the committee to develop policies and procedures, educate staff, and develop forms to implement the restraint reduction program.

Implementation

Staff education will play an essential role in successful implementation of new policies and procedures. New policies and forms should be reviewed with staff, and opportunities given for questions and answers. Members of the Restraints Committee can take responsibility for initiating specific practices and working with staff to follow through on new measures. 

Evaluation

Compliance with new restraints policies and procedures should be assessed frequently when first implemented, so problems can be solved as they arise. Designating a Restraints Committee member to oversee each area of change will assure follow-through. The committee members should examine the effectiveness of measures, and design new interventions as needed. Ongoing committee meetings, weekly or monthly, will assure continuing success of the program.

The State Operations Manual, Guidance to Surveyors, Probes: §483.13(a) suggests this systematic approach to restraint use: 

1. Identify the medical symptoms that led to the consideration of the use of restraints.

2. Evaluate if these symptoms are caused by a failure to:
   • Meet individual needs in accordance with the resident assessments
   • Use rehabilitative/restorative care
   • Provide meaningful activities
   • Manipulate the resident's environment, including seating

3. Attempt to eliminate or reduce the causes of the medical symptoms.

4. If the causes cannot be eliminated or reduced, attempt to use alternatives in order to avoid a decline in physical functioning associated with restraint use.

5. If alternatives have been tried and deemed unsuccessful, use the least restrictive restraint for the least amount of time.

6. Monitor and adjust care to reduce the potential for negative outcomes while continually trying to find and use less restrictive alternatives.

7. Explain risks, benefits, and alternatives, and assist the resident or legal surrogate to make an informed choice about the use of restraints.

8. Use the Physical Restraints RAP to evaluate the appropriateness of restraint use.

9. To maintain the residents' strength and mobility, re-evaluate the need for the restraint, and make efforts to eliminate its use.

                More information on restraint policies, procedures, regulations, and care planning can be found in the book: