Restraint Reduction: Regulations, Alternatives and Therapy Intervention

Editor’s note: This text-based course is a transcript of the webinar, Restraint Reduction: Regulations, Alternatives and Therapy Intervention, presented by Kathleen Weissberg, OTDS, OTR/L.

Introduction and Overview

Thank you for joining me for today's webinar on restraint reduction. As we begin, we will take a look at state survey guidelines as they relate to restraint reduction, and then we will review the new CMS regulations. Next, we will read through some restraint-related definitions, and learn about some of the reasons why restraints may be still used, as well as implications and effects of restraint use. We will analyze the physical therapist's role in restraint reduction assessment, as well as looking at restraint alternatives and specific interventions.

State Survey Guidelines

If you are familiar with Medicare, you know that there are new requirements of participation. Phase one was implemented in 2016. Phase two was implemented in the fall of 2017, and phase three is coming in 2019. Along with the new Medicare requirements, we also have new state survey guidelines. The guidelines that relate to restraint reduction are:

• F600 Free from Abuse and Neglect
• F602 Free from Misappropriation/Exploitation
• F603 Free from Involuntary Seclusion
• F604 Right to be Free from Physical Restraints
• F605 Right to be Free from Chemical Restraints

Note that guidelines F604 and F605 state that residents of assisted living facilities have the right to be free from both physical and chemical restraints.

CMS Regulations

I thought it was also important to review some of the new CMS regulations so that everyone is on the same page as we start to discuss interventions and defining the role of the therapist with regard to restraint reduction.

• 483.12: Freedom from Abuse, Neglect, and Exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms. Highlighting anything "not required to treat the resident's medical symptoms" is a huge part of these new and updated regulations. I think they've always been there, but what we're seeing now is a heightened awareness of that, particularly, from state surveyors who are making sure that, if we are using a restraint, there is a medical symptom to back it up.
• 483.10(e)(1): Respect and Dignity. The resident has a right to be treated with respect and dignity, including: The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2).
• 483.12(a)(2): The facility must: Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. 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-evaluation of the need for restraints.

Ideally, we would all love to be restraint-free, but that's not necessarily a requirement. What is a requirement is that the facilities use the least restrictive alternative and, if something is in place, that they're using it for the least amount of time. Facilities are also required to use proper documentation, not only to support the use of restraint, but also to show that the facility is regularly reevaluating those restraints, to either reduce or eliminate the restraint, or to implement other interventions. 

The guidelines are very clear that restraint reduction involves an interdisciplinary process. Residents should not be referred to therapy for the sole purpose or goal of reducing the restraint. No matter what type of facility is involved, that facility needs to design interventions to minimize medical symptoms, as well as identify and treat the root problem of that medical symptom (i.e., what's causing the need for the restraint). 

Restraint Definitions

Let's go through a few of the definitions as per the State Survey guidelines. We will first look at definitions as they relate to physical restraints, and then we will address terminology associated with chemical restraints.

Physical Restraint

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

What does convenience mean, with relation to restraints? Convenience is defined as "the result of any action that has the effect of altering a resident's behavior, such that the resident requires a lesser amount of effort or care and is not in the resident's best interest." In other words, it is for the benefit of the staff, not for the resident.

Discipline is defined as "any action taken by the facility for the purpose of punishing or penalizing a resident."

Freedom of movement means "any change in place or position for the body or any part of the body that the person is physically able to control." The person may not be safe standing or they may not be safe walking by themselves, but they still have that right to do so. We, as an interdisciplinary team, need to figure out how we can help that person to be safe.

Manual method means "to hold or limit a resident's voluntary movement by using body contact as a method of physical restraint."

A medical symptom is defined as "an indication or a characteristic of a physical or a psychological condition."

Position-change alarms are "alerting devices intended to monitor a resident's movement. The devices emit an audible signal when the resident moves in certain ways. They can be attached either to the bed or chair, or onto someone's clothing." These alarms can be considered restraints. Coming up, we will discuss position-change alarms in more depth.

Finally, removes easily means that "the manual method, physical or mechanical device, equipment or material, can be removed intentionally and upon command by the resident in the same manner as it was applied by staff." The physical condition and cognitive status of the resident may come into play here, as to whether or not they can remove the restraint. For example, a bed rail is considered a restraint if the resident is not able to put the rail down in the same manner as the staff does. A lap belt is considered a restraint if the resident cannot intentionally release the belt buckle. If, after three hours of fidgeting, the lap belt comes off the resident, that is not removing easily; that is fidgeting. There is a definite distinction between the two.

Examples of Physical Restraint Practices

Examples of facility practices that meet the definition of restraint include, but are not limited to:

• Bed rails that keep a resident from getting out
• Placing a chair close to a wall, heavy table, or other barrier to prevent rising
• Using a concave mattress that the patient cannot get out of
• Tucking in a sheet tightly so it prevents movement; fastening fabric or clothing in such a way that freedom of movement is restricted
• A chair that prevents rising (bean bag chair, recliner or Geri chair)
• Devices such as trays, tables, cushions, bars, belts
• Arm restraints, hand mitts, soft ties, vests
• Holding a resident down in response to behavioral symptoms, or when they refuse care
• Placing a resident in an enclosed, framed, wheeled walker that cannot be opened (e.g., MerryWalkers)
• Some position change alarms
• Reclining geri-chair
• Upright geri-chair with lap tray
• Devices that “hold” resident in the chair
• Seat belt, not self-releasing
• Lap buddies that cannot be removed

Examples of Convenience: Physical Restraint

It's important to recognize that we cannot impose any sort of physical or chemical restraint for the purposes of discipline or convenience. Furthermore, the facility is prohibited from obtaining permission from the resident or the resident representative (e.g., the family member) for the use of restraints when the restraint isn't necessary to treat a medical symptom. For example, in cases where the family members indicate that they want you to use a lap belt, if it is not being utilized to treat a medical symptom, we shouldn't be putting that in place. The families or resident representatives cannot dictate when we do or do not restrain. To reiterate, restraints should only be imposed when they are required to treat a medical symptom.

Examples of convenience include, but are not limited to:

• Staff are too busy or have too high a workload to monitor the resident
• Staff believes that the resident does not exercise good judgment; they forget their physical limitations when they are standing or walking, or they don't ask for assistance appropriately
• Staff state the family has requested restraint to prevent falls, particularly during high activity times (e.g., meals, shift change, medication pass)
• Not enough staff
• Temporary staff do not know the resident, or don't know how to approach the resident (e.g., if they have dementia or related behaviors)
• Lack of staff education regarding restraint alternatives
• Teaching the resident a lesson
• Preventing wandering
• In response to confusion or combative behavior, such as during ADLs (e.g., showers, clothing changes); holding down resident's arms or legs to complete the care