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Restraint-Free Care

There is a common misconception that restraints help improve the safety of frail elders. The truth, however, is that restraints are dangerous and often cause more risks than benefits. Many studies document the dangers and recommend more dignified methods to improve residents’ safety.

Reflecting this understanding, current nursing home laws aim to prevent the unnecessary use of restraints. Except in an emergency, a nursing home cannot use restraints without your consent. You have a right to be free from any restraint imposed for discipline or convenience. A restraint may only be used if your doctor has ordered it to treat your medical symptoms and only if the restraint will help you function at your highest level.

Despite strong California and federal protections against restraint use, far too many California nursing home residents suffer from unlawful restraint.

What is a Restraint?

There are two types of restraints, physical and chemical.

Physical restraints are items or practices used to restrict a person’s movement. They include leg and arm restraints, hand mitts, vests, soft ties, or anything else that prevents you from moving around. The way an item is used determines if it is considered a physical restraint. Trays, tables, bars and belts found on some chairs are considered restraints if they are used to restrict your movement and you cannot easily remove them. Other methods of restraint are moving your wheelchair against a wall so that you cannot move, using a bedrail to prevent you from getting out of bed, or tucking in a bed sheet so tightly that you cannot move.

Chemical restraints are drugs used to control a person’s behaviors when other forms of care are more appropriate. Psychoactive drugs, which affect emotions or behavior, are often used for this purpose. These drugs are not considered chemical restraints when used for the proper treatment of mental illness such as depression or schizophrenia. Psychoactive drugs are chemical restraints when they are prescribed to control an individual’s behavior without adequate medical justification.

CANHR has a special website devoted to stopping the misuse of chemical restraints and a consumer guide on this subject, Toxic Medicine: What You Should Know to Fight the Misuse of Psychoactive Drugs in California Nursing Homes.

Risks Caused by Restraints

Physical restraints are most often used to prevent someone from falling out of a bed or a chair. Although restraints may prevent some falls and accidents, they cause significant risks. Many residents have been seriously injured while trying to escape restraints or by improperly applied restraints. For example, many people have died from strangulation or been seriously injured when they became trapped or entangled in bedrails.

Other common side effects of physical restraints are incontinence, increased agitation, poor circulation, weak muscles, chronic constipation, pressure sores, depressed appetite, loss of mobility and increased illness. Restraints also diminish independence and social contact, often leading to withdrawal, depression, anxiety and agitation.

Even when used properly, most psychoactive drugs have numerous potential side effects. The dangers multiply quickly when these drugs are used as chemical restraints. Although the risks vary by the drug, some common side effects are agitation, sedation, disordered thinking, decreased appetite, constipation, low blood pressure and muscle disorders. One problem tends to lead to another. For example, residents who are over-sedated face most of the side effects caused by physical restraints.

Alternatives to Restraints

A nursing home has many options to help improve safety, including the following examples:

Methods to Improve Your Safety

  • Using pads and pillows to support you in a comfortable and safe position;
  • Adapting and tailoring chairs you use to ensure comfort and safety;
  • If you use a wheelchair, ensuring that it is the correct size, comfortable and in good condition;
  • Responding quickly to your physical needs such as hunger, thirst, sleeping, toileting and exercise;
  • Tailoring care and caregiver assignments to your preferences;
  • Providing therapy and restorative care to improve your abilities to stand, transfer and walk safely;
  • Using devices that monitor your efforts to rise from your bed or chair;
  • Helping you to get in and out of bed as often as needed and desired.

Methods to Improve Safety of All Residents

  • Increasing staffing levels to improve supervision;
  • Adapting the environment through good lighting, safe beds, alarms, and other features;
  • Removing accident hazards, such as over-bed tables with wheels and cluttered dining rooms;
  • Providing safe areas for residents to walk;
  • Training staff on methods to calm residents who are anxious or agitated;
  • Arranging mental health treatment for residents who need it.

A variety of strategies may be needed to improve your care and avoid use of restraints. The nursing home must carefully assess the symptoms that cause concern for your health and safety and consult with you and your representative about treatment options. Every appropriate option should be tried before restraints are considered.

Nursing homes must establish an individualized care plan for each resident that spells out care needs and how they will be met. For more information on care plans and your right to help shape yours, see CANHR’s Fact Sheet, Making Care Plans Work.

Right to Accept or Refuse Restraints

You and your legal representative have the right to accept or refuse any type of care or treatment, including restraints. Before restraints can be used, your doctor must seek your consent and disclose, at a minimum, the following information: (1) the reason for the restraint and why it is recommended; (2) the medical condition for which the restraint is needed; (3) the type of restraint that is recommended; (4) how long and how often the restraint will be used; (5) how your medical condition will be affected; (6) the nature, degree, duration and probability of known side effects; (7) the reasonable alternative treatments; and (8) your right to accept or refuse care and treatment.

You do not have to accept a doctor’s recommendation to use restraints. Except in an emergency, the nursing home cannot use restraints without consent from you or your representative. You can request the doctor and nursing home to use alternative methods of treatment. Before making a decision, ask your doctor and the nursing home these questions:

  • What symptom prompted the need for a restraint?
  • Has the cause of the symptom been identified?
  • What efforts have been made to treat or eliminate the cause?
  • Can the medical problem be treated without using a restraint?
  • What alternatives have been considered and tried? Are other options still available?
  • What are the risks and side-effects of using the restraint?
  • What are the nursing home’s policies on using restraints?

If the resident is capable of granting or withholding consent, only the resident may do so. If the resident lacks capacity to make a decision, then the resident’s representative may grant or refuse consent. A resident and legal representative can withdraw consent to use a restraint at any time. A nursing home cannot use a restraint when it is not medically necessary even if a resident or legal representative requests it to do so.

Under California law, persons who may act as your representative include a conservator, an agent designated under a valid power of attorney for health care and your next of kin.

Protecting Your Rights

If your rights are being violated, contact your local ombudsman office or CANHR for information on actions you can take. You have the right to file a complaint with the California Department of Public Health, the agency that licenses nursing homes. For information on how to file a complaint, see CANHR’s Fact sheet, How to File a Complaint Against a Nursing Home.

The most pertinent laws and regulations are found in:

  • United States Code: 42 USC §1396r(c)(1)(A)(ii)
  • Code of Federal Regulations: 42 CFR §483.13(a), 42 CFR §483.25(l)
  • California Code of Regulations: Title 22, Division 5, §72527(a)(5)&(23), §72528(b)&(c)

Page Last Modified: May 7, 2014