Training: Avoiding Physical Restraints

Training: Avoiding Physical Restraints

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What All Nursing Home Residents and Families Need To Know
Residents, family members, or legal decision-makers often request restraints because they think that the
restraints will protect against falls or injuries from a fall. In fact, the opposite is true. Research has found that
residents who are restrained are more likely to be seriously injured trying to get out of a restraint than they are
from a fall. In addition, there are many other negative effects that may result from using a restraint. These

• Loss of autonomy, dignity, and self-respect
• Feelings of isolation and dehumanization
• Feelings of entrapment
• Withdrawal, agitation, and depression
• Loss of appetite/malnutrition
• Bowel and bladder incontinence
• Urinary tract infections
• Loss of bone mass and muscle strength
• Skin problems, such as pressure sores
• Increased dependence
• Loss of mobility
• Muscle contractures
• Increased risk of fractures
• Death by asphyxiation or strangulation

What is a Physical Restraint?

A physical restraint is any article, device, garment, or method that (1) interferes with the free movement of a
resident of normal access to one’s body parts and that (2) the resident cannot easily remove. Many devices are
specifically designed to be a restraint (such as a vest restraint); however, there are many other devices that also
may restrict freedom of movement and which may be difficult to remove. These include a reclining chair, a side
rail, a tabletop, a lap buddy, a soft cushion, or a tightly tucked blanket.

Sometimes a device is a restraint for one resident but is not a restraint for another because a resident can easily
remove it or because it does not restrict a resident’s freedom of movement. One example is a side rail on the

A side rail is not a restraint for residents who use the rail to help them sit up in bed and who can exit the bed by
going around the rail or by going out the other side of the bed. On the other hand, the side rail is a restraint if it
confines a resident to the bed. Although some people think a side rail will keep a resident safe and in bed, the
opposite is often true. Residents have been severely injured or died because they became caught in the rails or
between the rails and the mattress. Others have been injured after climbing and falling over the rail. This may
be particularly true for persons whose conditions cause them to be confused or disoriented.

The Importance of Assessment

Physical restraints may be hazardous to the person who is restrained. For this reason, federal and state
regulations allow restraints only under limited conditions. They cannot be used to discipline a resident or for
staff convenience. They may be used only if they are required to treat a resident’s medical symptom and help
the resident achieve or maintain the highest practicable level of functioning and well-being. Except in
emergency situations where a resident’s health, safety, or welfare is in jeopardy, restraints should be used only
after less restrictive alternatives have been tried and have failed. To determine if a restraint is needed, a nursing
home must comprehensively assess the resident. They do this by:

  • Gathering as much information as they can about the resident’s condition, especially as it relates to
    the issue for which a restraint is being considered
  • Identifying all the alternative methods that could be used to treat the resident and keep the resident
  • Evaluating the results of past approaches and evaluating the pros and cons of using each proposed
  • Choosing the method they think will best meet the resident’s needs and will help the resident attain
    or maintain his or her highest level of functioning and well- being. If the nursing home determines
    that a physical restraint is needed, they must identify the least restrictive restraint and the least
    amount of time for using the restraint.

Before a restraint can be used, the resident or the legal decision maker must agree to the use of the restraint and
the physician must order the restraint. If the resident or legal decision-maker agrees to the use of the restraint,
the nursing home must ensure the resident’s safety when the restraint is being used and must plan for ongoing
evaluation to further reduce restraint use.

Decision Making

Residents have the right to make informed choices about all aspects of their care, including the use of a physical
restraint. A competent resident may request a restraint or refuse a restraint. If a resident is not competent to
make decisions, the right to refuse a restraint is passed to the resident’s legal decision maker. In Wisconsin, a
legal decision maker is either the resident’s guardian or the health care agent designated by the resident when
she or he completed a power of attorney for health care form. The legal decision maker may refuse a restraint
but, under federal law, does not have the right to direct the use of a restraint if it is not medically necessary. As
a result, a facility cannot use a restraint solely because a guardian or an activated power of attorney for health
care agent insists that a restraint be used.

If a nursing home thinks that a restraint is required, staff should explain how the restraint would help the
resident’s functioning and well-being. They should also explain the alternatives that might be used and should
discuss the pros and cons of each. There should be full disclosure so that the resident or decision maker can
make an informed judgment about whether or not to use a physical restraint.

A competent resident may request that a restraint be used; however, the nursing home is obligated to inform the
resident of the risks and benefits from using a restraint and of the alternatives that could be used. A nursing
home may ask the resident or legal decision maker to sign a consent form before using a restraint, indicating
that the resident or decision maker is aware of the risks and alternatives.

Alternatives to Restraints

After comprehensively assessing a resident, a nursing home may use many creative approaches to provide safe,
dignified care that meets the needs of the resident. Such techniques include the following:

  • Training staff to anticipate resident’s needs, such as toileting, assisting with ambulation, offering food
    and fluids, or offering medications for pain
  • Modifying the environment by reducing glare, creating non-slip surfaces, and rearranging furniture to
    promote mobility and to remove hazards
  • Maintaining a resident’s customary routines
  • Lowering a resident’s bed
  • Placing a mattress on the floor next to the bed
  • Arranging and using pillows on the bed instead of a side rail
  • Developing a mobility program to increase muscle strength and balance
  • Developing an activities program for those time periods when wandering or agitation increase.

Wisconsin Department of Health and Family Services / Division of Quality Assurance
PQA-3113 (Revised 03/08)



If you have any questions related to restraint use, please contact:
Division of Quality Assurance
PO Box 2969
Madison, WI 53701-2869
Phone: 608-266-8481

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