Restraint implies the use of physical, chemical or environmental measures to protect the person from injury to self or others. Using restrains on a resident is always a last resort. There may be times were using restraint is necessary, but all other possible avenues are to be explored first to ensure the dignity and well-being of the resident.
MAKING THE DECISION TO RESTRAIN OR NOT TO RESTRAIN
The risk to a resident’s health and safety must be identified and assessed in ways that consider the individuals choice, freedom of movement, dignity and respect, as well as the safety of those around him/her. The decision to apply a physical restraint or PASD which restricts movement is made by the interdisciplinary team. No one person can make this decision in isolation. When a resident is restrained, it will always be with the least-restrictive method available to manage the risk.
NOTE: Restraining a resident for convenience, as a form of punishment or discipline, or in the absence of risk constitutes abuse and may result in civil or criminal liability.
A freedom of movement-limiting PASD or restraint will be applied to a resident only after the following requirements have been met and documented:
NOTE: PRN orders will not be used to authorize the application of any restraint.
STIPULATIONS FOR OBTAINING CONSENT
Informed consent: As per the Health Care Consent Act is consent given after having received information about the treatment including the nature of the treatment, expected benefits, material risks and side effects, alternative courses of action, and likely consequences of having and not having the treatment. The person giving the consent must receive responses to any questions or requests for information that he may have about the matter. The decision to restrain a person involves a collaborative team approach including the resident and family, this process occurs in the following ways:
Substitute Decision Maker (SDM) or Power of Attorney (POA): The person who would be authorized under the Substitute Decisions Act, to give or refuse consent to a treatment on behalf of the resident, when the resident is incapable of making such a decision. The SDM must be notified prior to the restraint application and typically, a written consent must be signed within 1 week of the restraint is applied. In the event that a signed form cannot be obtained, verbal consent may be accepted and both the recorder and a witness must sign the form.
Imminent Danger: A situation where immediate action is necessary to prevent serious bodily harm to a resident or others. In situations where immediate action is required to prevent serious bodily harm to a resident or to another person, where alternatives have been considered and found to be ineffective, and where it is not possible to obtain an order from a physician, a registered nurse may apply a restraint to a resident without consent on an interim basis only. In such cases, the decision to apply a restraint and the rationale must be documented by the RN authorizing the use of the restraint, as well as all other less invasive interventions that were attempted before applying the restraint. This must be explained to the resident or incapable resident’s substitute decision maker (SDM) and documented by the RN. The Director of Care/delegate must be notified as soon as possible and a Physician’s order obtained within 12 hours of restraint application. In such cases, 15-minute checks of the resident are required until the device is discontinued. A restraint must be removed as soon as the imminent risk of harm has passed. Once discontinued, care shall be provided to ensure the safety and comfort of the resident is maintained in the post-restraining period.
As there are most likely underlying causes for certain types of behaviors, it is important to evaluate all of the residents’ symptoms (i.e. pain, infection, constipation) and the events that led up to the initial consideration of using a restraint. The assessment must be completed prior to application of a restraint and reviewed at least 3-6 months thereafter (depending on the individual facilities policies).
MONITORING AND REPOSITIONING A RESIDENT
It is essential to closely monitor the resident to which a restraint has been applied. Specific monitoring practices are:
TYPES OF RESTRAINTS
1. Physical Restraints: A physical or mechanical device that is used to intentionally prevent the movement of the whole or a portion of a resident’s body, in an effort to control their physical activities. Anything that is used as a restraint must be medically ordered. Examples of these types of restraints are:
NOTE: If the resident can physically and cognitively release the device by themselves it is not considered a restraint.
2. Chemical Restraint: A pharmaceutical given to a resident with the intention of using it to control behaviour or movement. Differentiating between the use of a drug, a therapeutic agent or a restraint is difficult. When a drug is used to treat “clear cut” psychiatric symptoms rather than socially disruptive behaviours, it should not be considered a restraint. Chemical restraints are not therapeutic agents; their use, to restrain a resident, is only permissible in situations of imminent risk, to prevent the resident from harming himself or others. Administration of a drug as a treatment in the resident plan of care is not restraining. The decision to use pharmaceuticals to manage inappropriate behaviour can only be made by the physician. He must write the order on the Physician’s Order Sheet and include:
3. Environmental Restraint: Barriers to a resident’s freedom, for the purpose of confining that resident to a specific geographical area or space in the home.
NOTE: Restraints are only applied with the written authorization of the client, the person responsible for their affairs (POA), or the physician. Since restraints are considered a temporary measure, continual evaluation is used to determine the ongoing need for restraint use. When a restraint is considered necessary, the resident and/or substitute decision maker (SDM) will be given an explanation of the reason for restraint application. Both physician and resident (or incapable resident’s POA or SDM) must review the need for the restraint and receipt of consent must be documented.
TYPES OF PASDs (Personal-Assistance Service Device)
A device which supports or stabilizes the resident so that his participation in a routine activity of daily living is facilitated. In some cases, as a side-effect, the device may restrict the resident’s freedom of movement in some manner. This may include a form of rehabilitation therapy that improves limb function in persons with stroke or other CNS damage by increasing the functional use of the affected limb. The unaffected limb is restrained, forcing the use of the affected limb with the goal of increasing the resident’s independence with activities of daily living. The use of a PASD that does more than assists the resident, and restricts movement or is used as a restraint, must follow proper restraint protocol. RPN orders for PASDs that have time-limited purpose linked to a specific activity of daily living are permitted; RPN orders for restraints are not. If a PASD is required and no appropriate device is available that does not restrict a resident’s mobility or freedom of movement, the least restrictive PASD will be proposed to the resident. The resident, or incapable resident’s SDM or POA, will be fully informed about the procedures and the consequences of receiving or refusing the proposed PASD and consent must be obtained before proceeding with its use. Some of the PASDs you may come across that can also be considered a restraint are:
Whenever the use of a PASD is considered, the least restrictive PASD appropriate to the circumstance will be used. A PASD that does not act as a restraint will always be considered first.
NOTE: If the resident can both physically and cognitively release the device by himself, it is not a restraint.
ALTERNATIVES TO RESTRAINTS AND PASDs
Behaviors progress from a calm state, to a mild state of anxiety, to a moderate state of anxiety and finally to a severe state of agitation. Interventions must be individually tailored to meet the unique need of each resident and the specific circumstance. The Patient Restraints Minimization Act states that one of its purposes is to “encourage hospitals and facilities to use alternative methods, whenever possible.” Some examples include:
The following devices/methods are PROHIBITED
In collaboration with the interdisciplinary team, alternatives will be explored, tried, and evaluated. As necessary, the Fall Risk Assessment Tool, Agitation Assessment Tool, and other risk assessments may also be utilized. If, after all, other alternatives have been exhausted and the decision is to proceed with a restraint, the nurse or other interdisciplinary team members will:
All significant information about each resident shall be documented in the Progress notes in the residents’ plan of care, whether in the Point Click Care (PCC) electronic health records database, Gold Care, or by pen and paper charting. The type of documentation depends on the specific facility you are working in. The person who documents the information shall note their professional designation, the date and time of the documentation if handwritten, all care that was provided to the resident and all events that have occurred. If documentation is done on the PCC system, it is vital that the staff completing the documentation for a resident has logged into PCC under his or her own name. Staff is not to share their log-in information with others and may not sign in with any other staff members’ name. When completing any documentation on PCC, the date and name of the individual completing the documentation will be inserted permanently into the note, care plan or assessment.
Paragraph style documentation may be used in progress notes on PCC in certain facilities. Personal Care Assistants shall document on activities of daily living (ADL) flow sheet, progress notes, and weight record. Nursing documentation shall include, but is not limited to: