According to the Centers for Disease Control and Prevention (CDC), there are 1.4 million residents living in the nation’s 15,600 nursing homes. Restraints are used on far too many, often under the misguided notion that they keep residents safe from falls.
The Centers for Medicare & Medicaid Services (CMS) made it a priority to reduce restraint use in nursing homes, resulting in 1,700 fewer physical restraints used between 2011-2014—a 34 percent decrease nationwide.
Quality Improvement Organizations (QIOs) across the nation were contracted by CMS to help with the reduction effort. atom Alliance, the QIO in Alabama, Indiana, Kentucky, Mississippi and Tennessee offered the staff at one nursing home help and they took it.
A few years ago, Quince Nursing and Rehabilitation in Memphis, Tenn., had a nearly 30 percent restraint rate with approximately 50 residents in some form of restraint. In three years, they were able to reduce that number down to one.
The facility was well above the national average of 10 percent of their residents in restraints, so they began looking at every resident to identify the root cause of each restraint used.
They knew there was always a reason why a resident falls. They just needed to figure out what it was.
Quince’s staff worked closely with their Director of Therapy Services, Ley Bayani, observing residents and meeting weekly to review falls and restraints together. They would discuss one resident at a time, and determine how to ease each one out of a restraint.
Often it involved an alternative, such as moving the resident from a standard wheelchair to a reclining or tilt-in-space chair.
For example, one resident was in a wheelchair with a lap buddy, a type of weighted belt, because he leaned forward, making him more susceptible to falls. Their solution was to convert him to a tilt-in-space chair.
Another resident liked to scoot around the building in her wheelchair, but she would come out of her seat and fall. The staff’s previous solution was to place a seatbelt on her, which made her irritated and angry. When they converted her to a tilt-in-space chair and she was able to safely travel throughout the building, her behavior naturally improved.
The biggest challenge to reducing restraints came from the families, who feared their loved ones would fall if not restrained. Tactics for overcoming these objections were constant education and an appeal to their emotions.
“Would you want to be restrained every day?” they would ask family members.
Bayani would offer articles and information to demonstrate the ineffectiveness of restraints, but that wasn’t enough. Family members needed options. So they offered alternatives and provided trial periods to demonstrate the safety of the restraint removal.
“Side rails got easier and easier to explain,” Maynard said. “The families felt protected by them, but we explained it could cause a worse fall or entrapment risk.”
The facility used their stimulation room for residents at high risk of falls. The activities team designed programs tailored to residents’ needs and the nurses supported them. They opened the room seven days a week.
Having tools, such as falls boxes, placed at every nursing station also helped staff quickly provide residents with activities and redirection when needed. Falls boxes are stocked with items that can be used to draw the resident’s attention to an engaging task, such as sorting colorful beads or organizing a purse.
It required more than persuasive words to reduce the staff’s dependence on restraints. Their habit was to use a restraint after someone fell, rather than try to understand the root cause of the fall.
To remove that convenience, they threw away every belt in the building.
“It makes it easier to reduce restraints when there’s not anything to restrain anybody with,” Maynard surmised.
With time, the staff became advocates for the residents to remain restraint free, especially when they realized their fall rate wasn’t increasing.
Maynard offers advice to nursing homes considering a restraint-free policy: “When you have so many restraints, it seems too big of a task to accomplish. Be patient. It doesn’t happen overnight.”
But it does happen, and Quince Nursing and Rehabilitation is proof.