Restraints are often used in nursing homes to prevent unwanted behavior in residents. Restraints may include physical restraints, such as Geri Chairs or bed rails, or chemical restraints, such as sedatives. Federal law prohibits the use of restraints of any kind unless absolutely medically necessary. In today’s episode, nursing home lawyers Rob Schenk and Will Smith discuss the inappropriate use of restraints in nursing homes with guest Diane Carter, RN, founder of the American Association on Post-Acute Care Nursing.
Schenk: Hello out there and welcome back to the Nursing Home Abuse Podcast. My name is Rob Schenk.
Smith: And I’m Will Smith.
Schenk: Right on it. Right on cue. Very interesting podcast this week. We’re going to be talking about restraints in nursing homes, restraints being either physical restraints or slightly less well known is chemical restraints, using medications to restrain nursing home residents. But because it’s such a deep topic, we wanted to go and recruit somebody that is highly knowledgeable about nursing homes and restraints in general, because we don’t want to give you less than perfect. We want to give you perfect. So we have a guest this week. And Will, who is this guest we have on talking about restraints?
Smith: We have Nurse Diane Carter. She is a registered nurse. She recently left her position as the founder, president and CEO of the American Association on Post-Acute Care Nursing, representing directors of nursing and nurse assessment coordinators in nursing homes. She managed the organization’s growth to about 17,000 nurse members across the country. She was active in the develop of the MDS 3.0 in the early 1990s and all regulation that affects long-term care since.
She has served on many technical expert panels related to long-term care regulation over her career. She served on the Advancing Excellence Campaign steering committee, the Board of Directors of the Colorado Culture Change Coalition, and is a member of the GNO Coalition through the Hartford Institute through the New York University.
Prior to forming AANAC, which is the American Association on Post-Acute Care Nursing, she was the associate director of the Colorado Association of Homes and Services for the Aging, now Leading Age. She also worked for the Colorado Department of Public Health and Environment as the assistant director of the health facilities division, which surveyed some 200 nursing homes in Colorado. She was the MDS coordinator for the state of Colorado, a CMS instructor and advisor on quality indicators development and a manager of the Colorado beta-test for the implementation of MDS automation.
Schenk: So what you’re saying is she’s qualified to speak with us.
Smith: She knows what she’s talking about.
Schenk: And actually to be quite honest with you, this is only half of her bio.
Schenk: Somebody that knows what she’s talking about. I just arbitrarily cut the thing in half. But anyways, without any further ado, Diane.
Smith: Let’s welcome Diane.
Schenk: Yeah, Diane, welcome to the show.
Diane: Morning, thanks for having me.
Schenk: Thank you. So as Will mentioned, you are extremely qualified to be talking to us. We feel humbled. We actually met, you and I, we met at the Long-Term Care Consumer Voice Conference last year in 2018.
Diane: Yes, we did.
Schenk: So we got your card and we wanted to have you on the show as soon as possible, so we’re glad that you could make it. But this week, we’re going to be talking about restraints in nursing homes, and as you could imagine, our audience is mostly families who have loved ones in nursing homes. So we want to do a 40,000-foot view of what restraints are and what to look out for, but in general, just to start us off here, what do you consider and what does the industry consider a restraint in the first place?
Diane: Well the first thing that I always consider is that there are all kinds of federal regulations around this issue because there have been abuses in terms of the use of restraints in nursing homes over the years. And to be frank, I started in this industry quite some time ago, and we routinely tied people in their chairs and did that sort of thing. It was just sort of – I hate to say it, but it was really the standard of practice when I was a kid working as a nurse aide in a nursing home. Not anymore.
But the federal regulations actually define a federal restraint as any manual method, physical or mechanical device, equipment or material that meets the following criteria: it is attached to or adjacent to the resident’s body, it cannot be moved easily or removed by the resident easily, it restricts the resident’s freedom of movement and normal access to his or her body. So it is noteworthy that easily removed means that the resident can intentionally remove a restraint in the same manner that it was applied by staff. That means they have the cognition and capability to remove the restraint.
So what are the different types of restraints? Well, there are all kinds, but they include Posey-belts, which is basically a cloth belt that would go around your waist, vest restraint in which a vest is placed on a resident, and then that is tied to a chair, a lap belt, Geri chair – Geri chairs used to be very frequent, they’re upright chairs with a tray table across them, and those were used as means of restraints, working to be viewed as restraint. There’s a thing called a Merry Walker, which is a framed, wheeled walker that is not – it’s considered a restraint. Concave mattresses were used for sometime because if you’ve ever slept in a bed with a huge dip in the middle of it, you know how hard it can be to get out of the middle of the bed. Also bean bag seating used to be okay because it didn’t actually tie someone down, but they couldn’t get out of that type of seating. Any time you used rails, tray tables, cushion guards, belts, hand mitts are sometimes used.
Schenk: So just so the audience is clear, the reason why, for example, a tray table would be a restraint is because there are some seniors or some residents in nursing homes where they would not be able to unlock the tray and get up and walk around. That essentially is a barrier to their mobility.
Smith: Or I actually worked in a nursing home too as a nurse’s aide back in the early 2000s, and what I would see is people would use the Geri chair, even without a tray, because if you lay a Geri chair back and you’re an elderly person who doesn’t have the core strength to sit up, it’s the same thing as a concave mattress. You’re essentially restrained by gravity in your own inability to sit up.
Schenk: I guess in essence, to summarize some of the things you’ve been saying in terms of physical restraints, it’s essentially if your intention is to make this person remain in one location…
Diane: Where they are.
Schenk: Yeah, it could be using anything. It could be putting something in front of a doorway, because I think the common misconception, Diane, is people think that people are tied down by leather straps, and in terms of the regulations of the federal government, that’s not the case. It’s anything that keeps you from being able to freely access the locality that you’re in.
Diane: It’s much, much broader than that, and in fact, it does include physician change alarms, where the resident is tied to an alarm, and if they move, an alarm goes off. Also bedrails are considered a form of restraint and are very dangerous. We’ve seen any number of situations, every year we see a situation where the mattress doesn’t fit the bed and the bedrail isn’t close enough to the mattress and the person is sadly – I don’t know how else to put it – they hang on the bedrail because they fall between the mattress and the bedrail. So there’s a lot of attention to all of those things right now, and as you said, we used to think of it as a Posey belt. Much broader now in terms of how we’re thinking about this and rightly so.
Smith: But it’s not just physical though, is it?
Diane: No, it isn’t.
Smith: Yeah, go ahead. Can you tell us about medical restraints, what chemical restraints are?
Diane: Well any sort of medication that prevents the resident from, well really interacting with their environment. Right now, there’s a huge, huge focus on appropriate use of psychoactive and antipsychotic medications in the field, and that was largely because – I don’t know – well for instance, there were medications that were put out that were called atypical antipsychotics, and they were Seroquel or Risperdal were used broadly across the field to sedate residents to the point where they wouldn’t have the kind of behaviors that are tough to handle in a nursing home, for instance, wandering behaviors and behavioral issues where the resident is actually combative about some issue. And so they would sedate the resident, basically, using antipsychotics and psychoactive medications.
Smith: Like I think I remember Haloperidol being one.
Diane: Yeah, that’s a pretty old one, but Haldol was one that was used – I don’t know your exact age, but years ago, Haldol was one of the drugs that was used, and that’s one of the really heavy duty antipsychotics, and those were clearly banned, but then the pharmaceutical companies put out these other two drugs that were called atypical antipsychotics, and so everyone in the world flipped to Risperdal and Seroquel and started prescribing it and now there’s a huge lawsuit and they’ve been – CMS has spoken out, rightly so, saying these shouldn’t be used in the elderly either, and now there are only very specific diagnoses – schizophrenia, psychosis, schizophrenic, Cunnington’s disease – I mean there are very specific diagnoses that you can prescribe an antipsychotic drug. You cannot just across the board.
Schenk: That actually brings up a pretty good point. So we talked about the means of physically restraining someone using mechanisms and instruments. The other one is using chemicals. Who are the residents, in your experience, in your collection of data, who are at most risk for being restrained by either method?
Diane: Well the top four reasons why people are restrained is to prevent falls, for behavioral issues, for wandering and for medical necessity. And so an example would be – I mean this is a classic example of just what you were talking about, if you have a resident that you’ve just put on an antipsychotic, which of course makes them dizzy and lose their balance and all types of vertigo sets in, and what happens? They fall. So you’re using a drug that creates the problem. And what do you do? Well you tie them down because you don’t want them to fall, because those are the things that show up on quality measures, so it gets to be a real vicious cycle there.
So when I talk about, for instance, behaviors, they start to give people drugs, and it’s just a vicious cycle, and there are so many good – a good assessment and a good intervention can prevent all of this. You just – there’s no reason to be using these sorts of drugs unless – like one of the things that struck me as quite funny about this issue with Risperdal, and it’s not funny, it’s ironical, but it is with Risperdal and Seroquel, is that all of a sudden, there were people being diagnosed as schizophrenic that were 90.
Diane: Now schizophrenic doesn’t appear when you’re 90. It just doesn’t. And so you have all these residents in nursing facilities that are being given these drugs, and so then because they have to put in a diagnosis, they put in schizoaffective disorder, schizophrenia, and then they say, “What? She’s 90 years and she suddenly developed schizophrenia?” And some of this medication stuff, in my mind, it’s just so predictable.
There’s a drug and I can’t think of the name of it right now. It’s all over the TV, but I had some contact with that pharmacy company because of my job before running the Nursing Assocation, but it’s a drug that’s used for the very, very, very, very few residents with Parkinson’s who may develop some sort of schizoaffective behaviors, right? It’s like 0.001. They put that on the TV and all these people out there, family members, they start to think, “Does my family member have this?” It’s very uncommon and I bet you 100 bucks we’ll start seeing that drug around all over the place. Another one – “Oh, this is intriguing to market. It’s intriguing.” Anyways, I think you see my point.
Smith: Yeah, absolutely. And to be clear, if we haven’t made this clear, the reason why these are so widely abused is that if you are a CNA and Mr. Johnson is going in and out of other rooms or he’s causing you to spend more time on him, it is very convenient to have Mr. Johnson in one spot, whether he’s in a Geri chair that he can’t get out of or he’s on some sort of antipsychotic that makes him sit in a chair all day and not want to move around.
Diane: So let’s use that example. That is a perfect example of something I’ve seen – a man or woman wandering around the building and going into other residents’ rooms, which is very, very annoying for other residents. We had a lady once we did that all the time, and our behavioral intervention was so simple. She’d go into drawers and dig through them, the chested drawers. We asked the daughter, “What’s causing this looking through the drawers all the time?” and she said, “You know, she was a librarian. Get a card deck with some cards in it and put it in front of her, and she will sit and look through those cards all day long. She’s looking for something from her past,” and you see that so commonly if you just put on your investigator hat and try and figure out what is it for this person?
We had a lady that every night, she wanted to go to the bus stop to meet her kids. She did that as a young woman. We went out to the end of the block, said, “Alice, it doesn’t look like the bus is coming.” She’d say, “Okay,” and she’d go right back into the building and we didn’t have to worry about elopement and all the other issues that go with these behaviors or tie her down or medicate.
Schenk: And that brings up another good point, Diane. You’re talking about interventions to reduce or eliminate the need to restrain at all. Where is the decision to restrain someone coming from in your experience and in general? Is it a CNA that’s doing it? Do you have to go to the DON? Where does the chain of command go with restraints?
Smith: And I guess along with that, are there circumstances where you can use restraints? It’s not just a blanket rule that restraints are wrong. There are circumstances, right, where you can use them.
Diane: Right. So what happens is if there’s some sort of issue, wandering behaviors, whatever it is that seems to be driving the need for a restraint, you need to call for a meeting of the interdisciplinary team, a care planning meeting. The resident and the family members need to be there to discuss what is going on in terms of behaviors, what might be causing the behaviors. Have there been any changes in medications? I mean there are a hundred things, so you need to really be thinking about what is this behavior about for this resident?
And in the very extremely unlikely circumstances that there’s a need for some sort of an intervention or a restraint, you would have to get a physician’s order for the specific type of restraint that you’re going to use, and how long it’s going to be used, how frequently it’s going to be evaluated, and what sorts of side effects you’re seeing with such a device.
Now when I think of most facilities in my state in Colorado are restraint-free. We’ve been teaching restraint-free environments for physical – although I will say I went to a class the other day and I had nurses from surrounding states arguing with me over why they needed to use a restraint.
An example might be a resident has an IV is being treated for – and I think this is true medical necessity, they might have maybe a feeding tube with some sort of infection that’s very irritated and they’re wanting to…
Smith: Pull it out.
Diane: Scratch at it or pull it out, and two things that we’ve used, although not recently, as the nurses were arguing with me, but anyways, two recent things we’ve used are soft mittens that go over the hands that just prevent you from having the dexterity to actually pull out an IV and in the older days, they were called feeding binders – it was just a binder that goes around the abdomen that protects the site of the feeding tube or whatever from someone getting their hands in there and scratching and causing the wound to get infected.
But there are so many options. I mean we use low beds, beds on the floor for people who fall frequently, but the most important thing is start where your doctors start every time you go to the doctors. The first thing your doctor says to you when you walk through the door and you have some issue, they say, “Have their been any changes in medication?” That is always the place to start in terms of did some kind of medication change? What happened when the medication change? Was some medication that they were on withdrawn? Because those have by far and away the most dramatic effects on wandering and behaviors and so forth. So those are the things you want to look at.
Schenk: You mentioned before, Diane, about the use of connecting the resident to an alarm. Can you talk more about that and how that is a restraint on a resident because I think some people might not realize that that is in fact a form of restraint?
Diane: Well given that it restricts a person’s motion, because the resident begins to think that, “I can’t move or else this alarm is going to go off,” and so we come to see those as restraints. The other thing is there is such alarms to keep now, they call it in nursing facilities, I mean there are alarms going off everywhere. So no one is paying any attention to them anyways.
Diane: Whether it’s a movement alarm within a bed, moving within a bed, my experience with alarms is that they are not very well calibrated either, so the slightest motion and you have an alarm going off in your ear. And so residents who can throw them across the room.
The other thing is we have the same issues with elopement where there are alarms on doors and on units. And I guess as with anything that’s not managed well, it’s useless. I mean it doesn’t work. And again, I would go back to all the ways of assessing for why is the person moving? What are they looking for? What are they moving towards? What causes them to move in ways that are dangerous?
And the problems with bed alarms is it’s usually about fall. I mean every person who’s over 50, I swear if you just look old, they put you on a bed alarm in a hospital now. And the fact of the matter is that everybody quits responding to them, it really doesn’t work. And so I think getting, again, I just can’t stress enough, figuring out what your assessment is and what it is and how it fits – I mean, they’re trying to keep the person from falling, but half the time, the person’s trying to get out of bed to get away from the bed alarm, and all of these things.
As with – I don’t know, maybe it’s just human nature, bed alarms and medications, I mean they all look like easy solutions when a really good nursing assessment of what’s going and what the person’s reacting to will solve nearly all of these problems. They really, really will.
Now to one of the questions that came up, one thing that I really, really want to stress is family members sometimes believe in their heart of hearts that it’s in the best interest of a family member to be tied in a chair. They really believe that to prevent falls, restraints ought to be used. And it could have changed some, but oftentimes you’ll find that families are really adamant about using a physical restraint, and they must be taught and educated about all the downsides to being restrained, all the psychological effects and physical effects of using restraints, and they need to understand that when a fall occurs with someone in a restraint, it is a far worse fall and they are much more likely to be injured than if they never had on their restraint.
Right now we’re going through all of the survey results looking at quality of care, I mean the worst incidents in the world are someone tied in a wheelchair when it flips over backwards or sideways. I mean that’s just a guaranteed really terrible injury, and so family members need to be educated about that. We know that most falls don’t result in injury. The vast majority of falls do not result in injury unless a walker, a wheelchair or something comes crashing down on top of the person.
And the other thing is when a surveyor comes in from a state agency and they start talking about restraints, the first thing they’re going to do is go to the resident and say, number one, did you request the restraint? Because there are instances where a resident wants a bedrail so they can reposition themselves in bed. And the next thing the surveyor is going to say is, “Show me that you can remove this restraint.” And they will. If the resident is physically and cognitively able to remove the restraint and he can do it, then that’s not considered a restraint. You and I deal with restraints every day – red lights at corners and so forth.
Smith: Seatbelts, yeah.
Diane: Yeah. We make choices about those things and know how to get out of them. The same applies for a nursing home resident. They should be able to say, “I want this because I need to be able to position myself in this chair,” or “It makes me more comfortable in this chair.” Whatever you want to put it, however you would want to say it, they have to be able to remove it themselves.
Schenk: So let’s say we have a family that’s been educated on the importance of restraint-free living in a nursing home. What are any telltale signs or symptoms or indicators that their loved one is being restrained either physically or chemically? Is there a way they can tell just observing and going there every day?
Diane: Well I think with chemical restraints, I mean with physical restraints, you’re very likely to – you can see the restraint. I would also look, I mean if there’s any evidence, and this would be where they’re trying to punish the person or in some way, I say punish the person, but for being whatever, some sort of behavioral problem, I would certainly start asking questions if I started seeing skin tears or bruising or the person seems fearful or they seem to be afraid of retribution for some reason, like for instance, this actually happened to me. I said my grandmother needed to go to the bathroom. My grandmother said to me, “Don’t bother them, Diane. You won’t be here tomorrow,” and, “Di, I can wait my turn,” she said. I didn’t like hearing that very much.
Smith: Not at all.
Diane: Yeah, and so I mean, it’s those kinds of situations where you feel like, are they being put in their room alone or isolated from other people? Are they talking about that? Are they unusually – just the sense that they’re afraid of something? Their behaviors really changed dramatically? Generally, you’ll see a physical restraint.
A chemical restraint, what I think of is you suddenly go into visit your loved one and you’re seeing malaise, sleepiness, loss of interest in any kind of normal activities, they’ve lost their interest in eating when they’re typically good eaters, and/or maybe slumped over. When I was a DON, I could tell immediately because they would often be slumped over in their chair often drooling. I mean you can see these behaviors and almost – now the facility is supposed to notify you if you’re the guardian or if you’re there visiting. They should be letting the family member know that they’re changing medications. They should be telling you, “We’ve changed the medications.” The family members, it’s really in their interest to be there frequently. There’s no better protection – I hate to say it that way, but there’s no better protection than being there frequently, being there every day if you can, getting to care planning, and really having an understanding of what’s going on for your loved one.
Diane: The staff don’t mean to hurt people but I think they’re busy sometimes and harm occurs. If you’re there and you’re asking questions, that’s good.
Smith: These places are notoriously understaffed. It’s just a part of what we have to deal with.
Diane: Right. Yeah. That’s why I left my job to fight for staffing.
Smith: We appreciate that.
Schenk: Well Diane, you’ve provided a lot of fantastic information. Is there any other last bit of advice that you would give to family members that have loved ones in nursing homes about restraints?
Diane: In terms of physical restraints and chemical restraints as well, I think it’s really important for families to understand about that temptation to want to tie somebody down and make an effort to figure out all the horrible side effects of these devices and understand what sort of assessment ought to be occurring and what sorts of interventions are available that will solve the problem without, for lack of a better phrase, it must cause tears in the hearts of residents to be tied down.
Schenk: Absolutely. Well Diane, thank you very much for that. We really appreciate you coming on the show and we’re definitely going to have to have you back again. You could speak on a whole myriad of subject matters when it comes to nursing homes, so hopefully you had a good time because we’d love you back.
Diane: I love this topic. It’s my favorite for many, many years, so thanks for having me.
Schenk: All right, Diane. Thank you so much.
Diane: Yeah. Take care, have a good day.
Schenk: You too. Bye-bye. I don’t think – I don’t want to say, I love all of our guests. I love all of them. But I think Diane is probably one of the most qualified, experienced people, guests, that we’ve had on this show. Man, she’s fantastic. She knows what she’s talking about.
Smith: I mean I think a lot of our guests are highly qualified and experienced, which is the reason we have them on.
Schenk: She’s the first of equals. She’s the first among equals.
Smith: Yeah, absolutely. But yeah, it’s interesting. She was part of the development of the MDS 3.0.
Schenk: Which I want to get her back on the show at some point.
Smith: To talk about the MDS.
Smith: That’s the minimum data sheet. That’s where they start pre-admission screening and start with acuities and start assessing the resident to give to Medicare, to give to CMS. So it’s an extremely important piece of reference material for a nursing home resident.
But what she’s talking about here is one of the most important, to me I think it’s extremely important overlooked aspects of nursing home residents’ lives, which is restraints. It’s easy to talk about the sexual abuse that goes on. It’s easy to talk about the negligence that goes on, resident-on-resident violence, which we’ll learn about next week and why we shouldn’t really use the term violence, but restraints are a – back when I was doing this 18 years ago, they were a huge part of what went on, and they were insidious in the sense that it wasn’t just that somebody was tied down.
There were so many different ways of restraining somebody using gravity, using the fact that they don’t have the core strength to sit up in a Geri chair, and it was done largely for the staff’s convenience because you’ve got some of these people who didn’t know what was going on, they’ve got a disease like dementia, and the staff gets exhausted and they’re understaffed already so it’s easy thing to throw Mr. Johnson in a Geri chair and lay it back. But what you forget is this is a human being and he has dignity. He was rights as a human being. And one of those rights is to not be restrained except within a very narrow set of parameters. And so I’m very happy that there’s somebody like Diane out there investigating this.
Schenk: That’s right. We’ll send her a Valentine’s Day card.
Schenk: Which is Thursday.
Schenk: So I think that we’ve brought this up every year, every Valentine’s Day, I think we’ve brought this subject up in terms of the – and why do I always forget the name of it? It’s the heart, the heart candy – they have a name. I forget the name every year.
Schenk: No. No, no, no. They’ve conversation hearts. Finally. It’s always been on the tip of my tongue. You dislike conversation hearts. I love conversation hearts. The original conversation hearts that were made by the New England Confectionary Company, which is now defunct and purchased by another company. So as we currently are recording this, the manufacturing of that candy is in doubt right now.
Smith: Oh, good. What a terrible, terrible candy.
Schenk: I love everything about that company. It’s NECCO for short – New England Confectionary Company.
Smith: Oh my God, it’s such a Yankee thing. My mom loves NECCO and she’s a Yankee.
Schenk: You know what? Very recently, and we can go long on the podcast with this story, very recently, I had tropical NECCOs for the first time, which is the wafers, which is made of the same materials as the conversation hearts, but they’re in little wafer forms, and it’s tropical fruit flavors, and the passion fruit one, it’s like you’re eating a little candy passion fruit.
Smith: Let me explain to you what a NECCO is. Depending on the flavor, let’s say that it’s fruit-flavored, a NECCO is like if somebody chewed some gum and then burped on a piece of chalk, that is what a NECCO is. It is a disgusting abomination of perishable item.
Schenk: I just don’t understand that. First of all, there’s nothing perishable about a NECCO.
Smith: Oh, not the NECCO. But it really is like a piece of chalk.
Schenk: Even digested NECCOs are…
Smith: It’s a piece of chalk somebody like got close to a strawberry and they were like, “Oh, put it like that,” and they’re like, “Here you go. It’s strawberry-esque now.”
Schenk: Well generally Valentine’s is not one of my favorite times of the year, except for the fact that conversation hearts are available for sale and I can consume them.
Smith: Well Daniela sounds like a lucky gal.
Schenk: Yeah. Yeah. So at any rate…
Smith: That’s his fiancée by the way.
Schenk: Still technically a fiancée as this goes to air, yeah.
Smith: Yeah, she, a month from now…
Schenk: Getting married, yeah. It’ll be close. So anyways, and with that – how do you consume the episode? Every week, you can get a new episode of the Nursing Home Abuse Podcast on Stitcher, iTunes, Pod Puppies, Google Play…
Schenk: Spotify, wherever you get your podcasts from, or you can watch at NursingHomeAbusePodcast.com or on our YouTube channel. And with that, we’ll see you next time.
Smith: See you next time.