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Routine Restraint of Nursing Home Residents Causes Growing Concern

December 28, 1989

WASHINGTON (AP) _ William Harmon used to spend each day tied to a chair in a nursing home, sometimes in a stupor, sometimes pleading for release.

″They’d just sit there all day long, everybody tied in restraints,″ said Mabel Harmon, who moved her 70-year-old husband out in August. ″I don’t think he would be living now if he hadn’t gotten out of there.″

Harmon’s situation was not unique. Two of five residents of American nursing homes routinely are tied to their beds or chairs, ostensibly to prevent injury, despite mounting concern that restraints may do more harm than good.

Harmon now is at Stapeley in Germantown, a Philadelphia home that is one of a small but growing number in the United States using no restraints.

″Since he’s been over at Stapeley, he’a a completely different person,″ Mrs. Harmon said. ″He does what he wants to do. He answers your questions. He walks up and down the hall. He goes into the lounge.″

Nursing homes say they use devices such as lap belts, wheelchairs with locking trays, and vests tied to beds or chairs mainly to keep residents from falling or wandering away and to control aggressive behavior.

Critics say restraints often are used for convenience and seldom eliminate the risk of injury. They say restraints can create problems including emotional withdrawal, depression, injuries incurred trying to get free, strangulation, constipation, incontinence, pressure sores, loss of bone mass, weakened muscles, decreased ability to walk and eventual invalidism.

″We have to ask ourselves: What price safety?″ said Jill Blakeslee, director of health services for The Kendal Corp., a non-profit Pennsylvania corporation governed by Quakers that has pioneered the concept of restraint- free nursing homes in the United States. ″Safe and quality care can be given to our frail old people without tying them to their beds and their chairs.″

Kendal and the Senate Committee on Aging this month sponsored a symposium, ″Untie the Elderly: Quality Care Without Restraints,″ where Blakeslee urged: ″Think about yourself as you grow old. Is that what you would want?″

Michael Plevyak’s family chose to place his 74-year-old mother, Genevieve, who has Alzheimer’s disease, at Friends Hall in West Chester, Pa., because it uses no restraints. ″The only thing she desires to do is move about and walk. That’s why we’re so thrilled that she is in a facility that allows her to engage in the one activity she gets any joy out of.″

Forty-one percent of nursing home residents were restrained in 1988, up from 25 percent in 1977, federal surveys show. Thirty-five people in U.S. and Canadian nursing homes strangled or suffocated from restraints between 1980 and 1987 and two burned to death trying to escape by lighting their restraints, the Press-Telegram of Long Beach, Calif., reported in a 1987 investigation.

In U.S. and Canadian nursing homes studied over the past decade, restraint rates ranged from 25 percent to 85 percent, Neville Strumpf and Lois Evans of the University of Pennsylvania School of Nursing reported in the January 1989 issue of the Journal of the American Geriatrics Society.

Family members initially may be horrified that a relative is restrained, but medical professionals ″can talk people into a big variety of things that afterwards they must wonder about,″ said Lynne Mitchell-Pederson, a nurse at St. Boniface General Hospital in Winnipeg, Manitoba. St. Boniface has nearly eliminated restraints since a patient strangled in 1981.

On the other hand, there are attorneys and family members ″wanting and willing to sue if a home doesn’t use protective devices to protect the safety of the resident,″ said Fred Watson, administrator of the Christian City Convalescent Center in Atlanta. ″We’ve got to get over that hurdle.″

Christian City was restraint-free when it opened 12 years ago but began using the devices under pressure from insurers, doctors and families, Watson said. It now restrains 20 percent to 30 percent, but is reducing that.

The widespread use of restraints is widely attributed at least in part to nursing homes’ fear of being sued, but some attorneys say reliance on restraints as a shield against litigation is largely unfounded.

In fact, a study of cases found that use of restraints produced more successful lawsuits than non-use, said Philadelphia attorney Alan Reeve Hunt, chairman of Kendal’s board. For example, an Alabama jury in June held a nursing home liable for $2.5 million in the strangulation of an 86-year-old woman in a restraint vest that was on backwards. The ruling is under appeal.

Restraints ″became a standard of care without ever being tested,″ said Sarah Burger, a consultant for the National Citizens’ Coalition for Nursing Home Reform. ″Everybody just assumed they did good.″

Growing concern about negative effects and recognition that restraints don’t eliminate legal risk are spurring a reduction. Thirteen U.S. nursing homes are known to be restraint-free, according to Kendal. Tough new federal rules take effect in October, and Florida has untied 3,000 people since August.

″There’s a contest going on to see who’s going to be the first restraint- free facility,″ said Florida licensing director Connie Cheren.

″This is not a movement in its infancy,″ said Nancy Dubler, an attorney in the Department of Social Medicine at Montefiore Hospital and Medical Center in New York. ″This is a discussion on the verge of bringing change.″

The Health Care Financing Administration reported last December that 8.5 percent of more than 15,000 nursing homes it surveyed were violating rules that allow restraints ″only when authorized by a physician in writing for a specified period of time or in emergencies.″

The new rules ban ″physical restraints imposed or psychoactive drug administered for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.″ Nursing homes for the first time will have to ″show that they have tried every other conceivable means to solve the problem,″ Burger said.

Removing restraints requires creative, individualized alternatives, said Beryl Goldman, Kendal associate director for health services. For example, cafe doors that sound a buzzer when opened might be installed on a wanderer’s room, brightly colored tape in front of exits help discourage confused residents from leaving, and rocking chairs can help active residents who need to be in motion.

One home was able to avoid restraining an 85-year-old woman who constantly paced with a doll but needed rest so her ulcers would heal, said Joanne Rader, director of mental health at Benedictine Nursing Facility in Mount Angel, Ore.

Staff members filled the doll with seven pounds of birdseed. ″Now, when she’s walking with the doll, she has a very heavy baby. So they said, ‘Oh, that baby’s so heavy. Why don’t you sit down and put your feet up?’ That’s a heck of a lot more fun than tying a person down,″ Rader said.

St. Boniface’s Mitchell-Pederson cited the case of an Alzheimer’s patient who disrupted meals and stole food. ″When we asked, ‘Could he be hungry?’ and doubled his calorie intake he stopped stealing food. ... In this case it was his diet that needed attention; restraints compounded the problem.″

An 85-year-old woman restrained in a chair for fear she would wander off and fall down the stairs was given shoes with rubber soles instead of slippers and ″was thus allowed to wander at will throughout the building,″ she said.

″There’s tremendous excitement out there ... toward developing and implementing a non-restraint philosophy. It’s no fun to be the one who has to tie someone down when they don’t want to be tied down,″ Rader said.

Some nursing home officials, however, caution that there are cases where there are no clear alternatives to restraints.

″While we all can agree that overuse or wholesale use of restraints is not desirable it is equally wrong to say no restraints should ever be used,″ said David Mettler of Hillhaven Corp., which runs 345 nursing homes in 38 states.

″This is not a black-and-white issue,″ Mettler said. ″Sometimes it may even be necessary to restrict the rights of an individual resident in order to provide for the health and safety of others.″

For dramatic reduction in restraints, residents and families must accept that ″if people have a certain amount of freedom, then they also run the risk of getting hurt,″ said attorney Joanne Ivancic of HFIC Management Co., which handles insurance claims for Hillhaven.

Benedictine has eliminated most restraints, but ″there’s maybe 5 to 10 percent of the people that I can’t figure out how get restraint-free,′ Rader said, citing as one example those who pull out tubes unless restrained.

Nursing home staffers who initially are skeptical about being able to manage residents without restraints usually find they prefer it, said Kendal’s Goldman. She quoted from a recent letter from a nurse at Friends Hall, which in 1987 adopted a no-restraint policy: ″I wouldn’t work any other place now. I wouldn’t have said that or believed it two years ago.″

Nine nursing homes in a Kendal demonstration program have reduced restraint use without increasing falls, staff or costs, Goldman said.

That is possible because residents who can move around generally stay healthier and require less care, Blakeslee said. Also, it takes a lot of time to properly apply restraints and remove them for exercise and use of bathrooms.

Stapeley in 1988 set a goal of untying five residents a month and a year later removed the last restraint, said Henrietta Roberts, executive director. ″I can’t tell you how the families have been pleased by this. The sense of humanitarianism, the sense that you are dealing with a person ... has made a great deal of difference. The patients are easier to care for.″

Supporters of the change at Stapeley include Bernie Lieberman, whose 89- year-old mother Frances had been routinely restrained after she fell and broke a hip. Now, staffers help her walk and she wears no restraints while seated.

″She seems much more cheerful and positive as a result of having more freedom,″ Lieberman said. ″Even though her mind was not working well, she was just the kind of person who wanted to get up and walk.″

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