Long-Term Care Survey Alert

Published on Wed Sep 09, 2009 PDF

Focusing on these specific clinical issues targets the cause of most restraints.

Physical restraints pave the way for numerous negative resident outcomes, including functional decline, pressure ulcers, depression, falls, and loss of dignity. On the other hand, trying to do restraint reduction on the fly has been known to tie up facilities in IJ citations.

The way out: A three-pronged framework can help you reduce restraint use in a way that wins kudos from residents, families, and surveyors.

Step # 1: Identify whether you're an outlier. One-fourth of the nation's nursing homes are at zero percent restraint use -- and another quarter are under three percent, noted Carol Benner, ScM, in a webinar on Advancing Excellence in America's Nursing Homes campaign. So if your facility is above three percent, it has some work it can do to eliminate some of those restraints, said Brenner, field director for the campaign.

Also, some facilities may be under three percent but want to become completely restraint free.

Step No. 2: Identify residents at high risk for restraints. Focus closely on residents who have falls, behavioral symptoms, and nine or more medications. Those are the issues that Quality Insights of Pennsylvania targets in helping facilities reduce restraints. Behavioral management is a "piece" that may be related to nine or more medications, observes Donna Balsley, RN, MBA FACHE, director of healthcare quality improvement for the state Quality Improvement Organization.

When an elderly person starts taking multiple medications, he may become agitated or confused or be at risk for falls, Balsley tells Eli.

Watch out: Even single medications can up the risk of falls and restraint use -- for example, a drug that causes dizziness, gait changes, or delirium. Over-treatment of high blood pressure can also lead to falls, noted Steven Levenson, MD, CMD, in the Advancing Excellence webinar. That can happen when caregivers "excessively measure" blood pressure and report fluctuations, which results in unnecessary or additional medications to lower blood pressure, he cautioned.

Step No. 3: Develop effective fall and behavioral management programs. Anticipating residents' needs goes a long toward preventing falls and behavioral symptoms. "Happy people don't jump up and fall down," said Diana Waugh, RN, BSN, who spoke during the Advancing Excellence webinar. For starters, facilities should do cognitive functional testing to determine how well residents can understand what staff say, Waugh counseled.

Forget reality therapy: The right communication strategies can head off agitation, aggression, and wandering that pave the way for restraint use in some cases. Staff members tend to make two key mistakes in communicating with people with dementia, Waugh noted. For example, when Mary, who's 98, says she has to go get her Mom to go shopping, the staff person shouldn't say, "Mary, your Mom is dead," Waugh counseled. That statement can hurt as bad as the first day Mary's Mom died because Mary doesn't remember that her mother died, Waugh noted. And all of a sudden Mary becomes agitated and goes off to look for her mother.

Another example: The resident says, "I have to go home." In an attempt to be nice, the staff person says, "You are home." Now the person with dementia is really scared, said Waugh, because not only does she not know where she is -- the staff person doesn't seem to know either. A better intervention would be to say, "Tell me the neatest thing about your house," Waugh suggested.

"And because you did your preadmission visit," you can talk about how many gallons of paint it took to make that red front door.

Real-world scenarios: In one situation caregivers figured out that a resident with behavioral issues and a history of falling liked to look at his own photojournalism work, noted webinar copresenter Terri Hatfield, LPN. So the family helped develop what they called a "a happy book" containing the resident's photos, which calmed him. Another resident was constantly trying to leave the facility to visit her family members. So the staff got her a tote bag and inserted photos of her family members in transparent pockets on the front of the bag.

The bag also contained her favorite stuffed animal.

"We attached [the tote bag] to one side of her wheelchair, so when she went looking for her family members, we could show her" the pictures and say, "Your daughter is going to be here this afternoon."

More tips: Provide individualized toileting schedules -- a tactic that the Pennsylvania QIO uses in helping facilities prevent falls that can lead to restraints. Unrecognized or under-treated pain and related behavioral manifestations represent one of the major physical reasons for restraint use, cautioned Waugh in her presentation.