What Are Chemical Restraints in Nursing Homes?
When does medication become a chemical restraint in a nursing home? Medications may sometimes be necessary for a resident’s care, but using drugs to control or restrain a resident can raise serious safety and legal concerns. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes Evan Jones to discuss nursing home chemical restraint cases, resident rights, and what families should know.
Schenk:
Sometimes a nursing home restraint does not look like a strap, a belt, or a bed rail. Sometimes it comes in the form of a pill cup. I’m attorney Rob Schenk. This is the Justice for Residents podcast, and this week, I’m joined once again by Georgia trial lawyer Evan Jones to talk about chemical restraints, how to spot them, how to prove them, and why the case may not necessarily start off as a chemical restraint case, and why some facilities reach for medication when they should be reaching for more staff.
Stick around.
I can say that the intro jingle really takes me back to my Super Mario days. I think that I got my first Nintendo… How old would I have been? Nine years old? So this would’ve been like maybe ’87. ’87 or ’88, and this is, that’s, that chiptune music is etched into my brain. For the next four or five years, that’s what I was all about.
Anyway, great episode today, folks. We have the fantastic Evan Jones on. We’re gonna be talking about chemical restraints. If you want more homework, we all want more homework, then I would suggest that you go back in time to episode 170, which came out in April of ’21, where we talk about anti-psychotropic medication.
We did that with Dr. Nancy Burtley. Episode 196, we flipped the script a little bit. We had an episode about how you can treat certain clinical conditions without pharmaceuticals, and we did that with Dr. Helen Kales. So episode 170 and 196, I think are good primers for what we talk about in this particular episode.
And of course, if you wanna go, if you wanna hear more from the fantastic Evan Jones, he was on the podcast before, episode 215 in September of ’24, where we talked about nursing home cases that involved resident-on-resident violence. So be sure to check those episodes out and get ready for an amazing conversation.
Guest Intro
Schenk:
Evan Jones, a personal injury attorney at Blassingame, Burch, Gerard, and Ashley, specializes in catastrophic injury cases, including medical malpractice and nursing home negligence. With extensive experience, he has secured substantial settlements and verdicts totaling in the millions of dollars for his clients.
Evan’s background includes serving in the US Army Judge Advocate General’s Corps and representing medical institutions and personal injury clients before transitioning to the plaintiff side. His dual perspective enhances his ability to fight for clients effectively, and we’re so happy to have him on the show again.
Follow BBGA Law on Instagram for firm updates, legal insights, and educational content.
What Is a Chemical Restraint?
Schenk:
Evan, so let’s start quickly at the beginning. What is a chemical restraint?
Jones:
Chemical restraint in its most basic form is, at least in a nursing home or even probably an assisted living scenario, would be when healthcare providers such as nurses give a resident a prescribed medication, for instance, or too much medication even in some instances, for convenience so they can finish their job or as a form of punishment, and that’s essentially the OBRA definition as well as the Georgia Bill of Rights for long-term care residents.
How Are You Establishing That Medication Was Used to Restrain Rather Than Medicate?
Schenk:
How are you in a chemical restraint case, how are you establishing that the mens rea or the intent was to restrain versus, we’re within the range of how we should be prescribing this medication?
Jones:
The chemical restraint cases I’ve had and even some that I’m working on currently it’s relatively simple in most regards, is the resident is found to have medications in his or her system that are unprescribed.
For instance, Schedule II narcotics for residents who have behavioral issues. And a lot of times it’s just by sheer luck that the physician who is trying to determine what is wrong, why, for instance, what has there been a significant change in the resident is the resident clearing his prescribed medications with an impaired renal function, for instance.
And so he gets back these urinalysis that, lo and behold, test positive for medications he has not prescribed. That’s one thing, that’s the easy way, but it’s almost sheer luck that you get something like that. The other way of proving it is you look at the resident’s records day in and day out, and you start seeing these times where…
and let’s face it, it’s usually these more difficult residents that are chemically restrained. And it’s also one of the reasons these nurses and other healthcare providers chemically restrain these residents so they can get their job done. You were just talking with Ernie about staffing.
How Can Understaffing Lead to Chemical Restraints?
Jones:
Understaffing is a leading cause behind the question, why did nurses cross the line and chemically restrain a resident? You’ll find that they’re taking care of too many residents, and that this particular resident that’s been chemically restrained takes a lot of time in these nurses’ twelve-hour shift, seven to seven shift, let’s say.
And you’ll find in the record that the resident is baseline, is usually a lot of attention getting in and getting out of bed, for instance very needy, for instance. And then all of a sudden you find these times where the resident is almost comatose, and it is a significant change of condition that makes one suspicious that the resident during that time has been chemically restrained.
So you start looking at the MAR and any other documentation about what type of medications has this resident been prescribed during this time frame. For instance, if it’s a PRN oxycodone, you really start looking at if it’s PRN, instead of every four hours, did they give it every two hours?
Did they give it every hour? And you start seeing. And that’s evidence of a chemical restraint, if they’re using it for convenience at that point, or perhaps discipline, but mostly convenience so they can get their job done. But that’s a prescribed medication. And it’s a PRN medication that’s often on many residents’ charts.
So you have to really, fly spec the MAR and the changes in the resident’s condition to look at whether you believe this resident was chemically restrained. And it happens in a lot of cases and it leads to additional problems like less mobility, which leads to malnutrition, dehydration, skin breakdown.
You’ll find that even in your wound care cases, sometimes residents for periods of time have been given too much medication by the nursing staff, even if prescribed, and that is a form of chemical restraint. And it all goes back usually to understaffing during a particular shift where they just can’t take care of all these complex residents with complex medical needs.
Families and caregivers can learn more on the impact of preventive health measures in elderly populations and the importance of recognizing potential signs of mistreatment in vulnerable older adults.
You throw in a resident, for instance, that, instead of the usual sixteen minutes that you have for each resident, depending on the occupancy level of the facility you may have you may have to treat this resident for thirty minutes, and that throws off the rest of the time that you have with other residents.
So nurses, in an attempt to try to get their job done… I haven’t seen, for instance, Rob, nurses that have tried to intentionally harm a resident. It’s usually when you have these chemical restraints, it’s nobody’s listening to us, we’re understaffed, and we wanna get our job done. And they give these residents, either too much…
It’s usually a narcotic, because a narcotic or a benzodiazepine can knock them out. And they give them that, and they don’t understand how that’s gonna affect that resident. That’s why doctors prescribe it in the first place, and that’s why they give you a specific amount to prescribe. And nurses are at a disadvantage because they don’t study pharmacology like a doctor, and they can’t put the picture of the resident together and say, “Hey, we’re not gonna give this resident, for instance, too much oxycodone because he’s got impaired renal function and can’t clear it.”
And so they’re not thinking about stuff like that. They’re thinking about, “We’re, we just need a break from this guy, so we can take care of the rest of the hall.” And so they give him too much oxycodone, and lo and behold, he’s got he’s predisposed to aspiration. He’s predisposed he’s got COPD.
So where morphine, for instance, or hydrocodone, or even Xanax or Ativan by themselves are going to suppress a, or depress, I would, should say, respiratory system. You start putting them together, and this is what nurses don’t understand. Concomitantly they cause very deadly circumstances with these eggshell plaintiffs, which we have in every case, and bad things happen.
Additional research provides insight on the impact of preventive health measures in elderly populations and the factors that can influence the detection and prevention of elder abuse.
What Injuries Can Result From Chemical Restraints?
Schenk:
That’s a good segue. When you have a chemical restraint case clearly the chemical restraint itself is a cause of action. It’s a dignity issue, et cetera, which has its own damages. But it sounds to me what you’re describing is often in our chemical restraint case, the damage comes from an injury due to the restraint, right?
Yes … so talk about your typical, other than the dignity of being restrained, talk to me about the injuries that you see in a typical chemical restraint case.
Jones:
You’ve hit on the obvious. It’s a dignity, it’s a self-worth issue. But, and usually if the person’s been chemically restrained it causes a significant change of a condition.
Most of the cases I’ve dealt with, it has either caused significant respiratory distress, which leads to… it can lead to choking, it can lead to aspiration, it can lead to pneumonia. It can lead to, if it happens often, it can lead to malnutrition, dehydration. They are not going to eat, they’re not going to drink.
And occasionally because it impacts their already limited mobility and they’re already at high risk for skin breakdown based on their age and other comorbidities, pre-existing medical conditions it can lead to significant wound issues as well. And that cascades down to, increased risk of infection and increasing, as the doctors would say, mortality rates, increases their risk of death in lay terms.
And the interesting thing is these nurses know that these medications, and if they’re used to chemically restrain a resident, have these deleterious effects. They just don’t know, because they don’t have the medical training, that it could kill the resident. It could cause a wound, an infected wound or be a cause and/or contribution using the Georgia standard.
Not the cause, but a cause and/or contribution to the decline and eventually the death of this resident. So you have to… it’s an analysis of the records, and if you start seeing a resident and, or if you have a family saying, “Hey mom or dad was a handful,” or the nurses had to spend a lot of time for whatever reason with them. But then there’d be these, be these periods for like days even that they would be sitting there and and just not themselves.
And you’ll hear something like that. And then they developed a wound or they stopped eating or they had aspiration pneumonia. Then you’ve got a… or they choked and died. The significant factor in that might be a chemical restraint. It might not just be a choking case, it might be a chemical restraint case.
Behavioral changes, unexplained injuries, and poor hygiene may be warning signs, so families should understand how to tell if a loved one is being neglected or abused.
Can a Choking or Pressure Injury Case Turn Into a Chemical Restraint Case?
Schenk:
Okay, great. So the idea here though is when typically for you, Evan, when the resident’s family approaches you, is it typically that you’re investigating a chemical restraint case or you’re investigating a choking pressure injury case that becomes a chemical restraint case?
Jones:
Exactly. It’s usually a choking or a pressure sore case that becomes a chemical restraint case as you start delving into the records, particularly when you start looking at what types of medications. And I think it happens, Rob, more often than not. I don’t have the statistics before me, but I think it goes obviously unreported because they’re not saying anything.
But I think it happens quite a bit. I’ve started seeing in my cases with these more difficult residents that have really low BEM scores, they suffer from dementia of some sort, whether it’s age-related dementia or vascular dementia, Alzheimer’s even, and they’re just, they’re very difficult to take care of.
You can look at that just on daily nurse’s notes. You start seeing, especially with these PRN meds, nurses start giving these meds- so all- lo and behold, they’re always in pain, and pain is real, and a lot of times they have chronic pain syndromes. But we had a case where I think they must have given 15, 20 times a day. Oh, wow
Oxycodone. And when they’re giving Oxycodone 15, 20 times a day and pain levels aren’t changing, that’s a chemical restraint. That’s a chemical restraint. A- and it’s a prescribed medication. The physician a lot of times just doesn’t know that the nurses are taking advantage of this PRN.
And if for those of you who do not know what PRN means, as needed. It’s the prescription that, hey, you give grandfather Oxycodone as needed if he’s in pain, not because you want to complete your job. First of all, he gets addicted to it. And we’ve seen that too. We’ve seen these opioid use disorders that have started to happen in nursing homes of all things.
And they start wanting this Oxycodone, and they start yelling at the nursing staff, “Give me my pain pills,” too. That’s another sign and symptom is if they’re asking for a lot of pain medication but their Wong-Baker pain scale from zero to 10 stays at two or three chemical restraint case.
Early identification can help protect vulnerable residents, making it important to know how to recognize signs of nursing home abuse.
Question of the Week
Schenk:
All right, folks, now it’s time for the Nursing Home Question of the Week. Forgive my interruption. This week, the difficulty level I’m gonna say is hard. This is pretty difficult. So if you get this right, then… Okay, so you, there’s that concept, and I think they made a movie about it, where hippie parents will say…
There’s a day where they say yes to whatever their child suggests. “Mom, I wanna eat pancakes on the roof.” “Okay,” you gotta say yes, right? Today, it’s the opposite. You can say no to anything. Even the most reasonable request from your kids, you can say no to if you get this question right. So it’s like the, it’s the say no to anything day.
Under 42 CFR 483.35c4, the director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of A, 15 or fewer residents, B, 45 or fewer residents, or C, 60 or fewer residents.
And that answer is C. The DON may also serve as a charge nurse only when the facility has a daily average occupancy of 60 or fewer residents.
What Red Flags Should Attorneys Look for When Investigating Chemical Restraints?
Schenk:
So it sounds to me as if you’re investigating a case for choking, pressure injury, whatever it is, the kind of the red flag or what sticks out to you in that investigation process is the behavior of the resident. Is the resident a wanderer? Are they combative? Yeah. And then if you see that, then you look and see, okay was there a change?
Was the resident, you start looking at the MARs. You start looking at the MARs more closely if you also have that, was the resident combative? And then you see, okay, there is oxycodone, and then you follow that, that rabbit hole. But it starts with the resident was clearly a behavioral, quote unquote, problem for the nursing home.
Jones:
Yes. And that can be a broad term, a behavioral problem. It can be a resident that just takes up a lot of their time and doesn’t necessarily. A lot of times it is a resident that has these behavioral issues and and let’s face it, it’s hard being a, a nursing home employee, especially when most business models in nursing homes are profits over people, so they’re gonna understaff intentionally or understaff to the point where they can’t meet the resident’s needs per OBRA.
And so with that setting it often is a resident that has acted out, and that’s the easy setting. But it can also be a resident that still is to some degree continent, but needs assistance, let’s say a two-person assist to, for toileting, that takes up a lot of time and a lot of effort.
Say you have a resident that has some obesity and they have to use a Hoyer lift or to get this resident into a wheelchair or get this resident to the bathroom. You might start seeing it in that. It’s going, again, most of the cases we see, we don’t see a lot of these punishment cases.
I have seen what I thought was punishment before in chemical restraint cases. It’s the convenience cases, and that’s a, any, any time that, they give a resident too many medications, or even the easy one, unprescribed medications for convenience. There could be a lot of different scenarios.
It could be behavioral issues versus just a very needy resident,
How Do You Prove Causation in a Chemical Restraint Case?
Schenk:
I can see how a chemical restraint case, if it’s on the margin, can be extremely difficult, because you’re having to show that the medication was improper for the purposes of convenience or punishment, and then you have to show that the, that overmedication or improper medication is the cause of whatever the injury was.
I understand when somebody gets 20 oxycodone pills a day, that makes the case not easy, but easier. But when it’s a borderline case, I could see it being a very difficult matter
Jones:
It’s more difficult on causation, but let’s remember that, and I’m about to argue this actually Tuesday in a chemical restraint case that’s going to trial in August in court in response to a motion for summary judgment.
It is, in Georgia, it is not the cause, it is a cause and/or contribution to the pain and suffering, the decline and death, the injuries. So if you can link that up from a medical perspective, and you’ve got a good expert that says, the chemical restraint, was a cause and/or contribution to a fall, to a wound.
And often, again I bring this up, look at your fall cases. Many fall cases are, emanate or begin as a chemical restraint case because they fall because they’re, the polypharmacy issue of being on too many medications, and you start looking at it and going, “Oh, lo and behold, I think they were given too many pain medications, and they get dis- disoriented, they get up and they fall.”
Cause and/or contribution, that is so key to understanding the causation standards, particularly with these residents with preexisting morbidities that these experts have to take into consideration, age, infirmity and then the outcome, and you throw in there a chemical restraint.
It just has to be a cause and/or contribution.
What Documentation or Evidence Is Best for Showing Improper Restraint?
Schenk:
You’ve discussed at the top of the episode kind of the unicorn situation where you have labs from a hospital or a physician that shows the overmedication or the polypharmacy. You’ve discussed MARs are a good place to go for the evidence or the record, the nursing records.
When you’re deposing people in a chemical restraint case, do you have a particular approach? Is there, if you are just trying to elicit from a CNA or a, a nurse that such and such a resident, would get up and walk around or, and, was a problem? What’s the strategy that you have in these kinds of cases for depositions?
Jones:
It goes back to, similar to if you’ve ever watched true crime on Netflix. They rarely confess to over-medicating or giving unprescribed medications to these residents. So you have to look at means, motive, and opportunity. And, who had the means to do this?
It’s usually the nurses. They are psychotropic, we’ve seen those types of meds with chemical restraints, usually pain medications, benzodiazepines for anxiety and such. They are kept in locked medical carts. Who has the key to the medical cart? The nursing staff.
CNAs don’t, administration doesn’t. It’s the shift nurses and perhaps the DON. So when did the resident’s condition change that you’re suspicious of a chemical restraint? You look at that shift. You’ve got to usually get a pharmacologist, toxicologist to link up, if the medication was given the shift, would you have this kind of outcome?
A geriatrician helps as well. But going back to means, motive, and opportunity. Motive, who had the most motive to do this? It’s usually the nursing staff again because they can’t take care of their other residents. And that’s where, Rob, to your point, you start looking at these behaviors and going, “He was a pain in the ass.”
Difficult resident, had to resurrect him, had to get him back in bed, had to toilet him, whatever it may be, 15 times a night That’s your motive, that’s their motive of, hey it, they’re constantly having to deal with a difficult resident. And then opportunity did it happen during a night shift?
Was there anybody else there? Are there video cameras? Very important to put your spoliation letter out there and have them preserve any video, because medication rooms and medication carts are not in resident rooms, they’re out in common areas where there are, where there is video that can be accessed or should be accessed.
Families evaluating suspicious treatment can learn what constitutes nursing home abuse and when conduct may warrant further investigation or legal action.
Schenk:
Evan, very well said. I like the true crime connection. We’ve- Me and my wife are watching the, There was, like, a Michael Jackson trial documentary on Netflix- … that we were just watching. But we really appreciate you once again coming back on the show and sharing your knowledge with us.
Jones:
I appreciate it. Thank you for having me, and best of luck.
Schenk:
Folks, I hope that you found this episode educational, informative. If you did, please be sure to let me know. Always be sure to like and subscribe wherever you get your podcasts from. New episodes of the Justice for Residents podcast come out every single Monday.
If things go according to plan, then this episode should be coming out towards the end of Dec- of September of 2026. So it should be September 28th as this goes to air, and if it does, I want everybody to have a Happy World Heart Day, which is tomorrow, the Sep- September 29th. Take care of your heart tomorrow.
Just eat plain Cheerios and no bacon. So that’s, actually, that’s not really a good celebration for me. Just eat some bacon, but take, what is it called? Statins. Take some statins, eat some bacon. And with that, folks, we’ll see you next time.
Thanks for tuning in to the Justice for Residents podcast. Nothing said on this podcast, either by the host or the guest, should be construed as legal or medical advice, nor is intended to create an attorney-client relationship between the listener and either the host or any guest. New episodes are published every Monday and are available on all your favorite podcast apps, as well as on YouTube and our website, justiceforresidents.com.
Again, that’s justiceforresidents.com. The Justice for Residents podcast is hosted by Rob Schenk, a trial lawyer representing victims of nursing home abuse and neglect throughout the state of Georgia. We’ll see you next Monday.