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The legal use of restraints
LAW AND THE EMERGENCY NURSE
The Legal Use of Restraints
Authors: Genell Lee, MSN, RN, JD, and Diane Gurney, RN, MS, CEN, Montgomery, Ala, and Hyannis, Mass Section Editor: Gail Pisarcik Lenehan, RN, EdD, FAAN
Genell Lee, Metro Birmingham Chapter, is Executive Officer, Alabama Board of Nursing, Montgomery, Ala; E-mail: [email protected]. Diane Gurney, Mayflower Chapter, is Trauma Coordinator and Educator, Emergency Center, Cape Cod Hospital, Hyannis, Mass. Reprints not available from the authors. J Emerg Nurs 2002;28:335-7. Copyright © 2002 by the Emergency Nurses Association. 0099-1767/2002 $35.00 + 0 18/9/126358 doi:10.1067/men.2002.126358
August 2002 28:4
I
t is the evening shift in a busy emergency department. A coworker called in sick, leaving the unit short staffed, and one of your patients constantly calls out. She is disoriented and repeatedly tells you that she wants you to take out her intravenous line and let her go home. A colleague suggests you restrain the patient. Should you? The process of restraining a patient who is judged to be confused or combative used to be fairly straightforward. You simply obtained a physician’s order (in an emergency, you did not even need an order until later) and restrained the patient. However, recent federal regulations have had an impact on the decisions and processes involved in restraining a patient. The Centers for Medicare & Medicaid Services (CMMS) (formerly the Health Care Financing Administration) published revised Conditions of Participation in July 1999.1 Facilities that receive Medicare funds are governed by these Conditions of Participation. CMMS standards state that patients have a right to be free from restraint or seclusion, and they prohibit the use of restraints for staff convenience, punishment of patients, or as a retaliatory measure. One key prohibition is that there should not be physician orders for prn or as-needed restraint or seclusion. When restraints are used, it is required that documentation be provided in the medical record to the effect that less restrictive interventions have been “determined to be ineffective.”1 The documentation at Cape Cod Hospital actually has a list of alternative measures that have been tried prior to resorting to restraint and or seclusion, such as orientation, modification of environment, diversional activities, having a family member sit with patient, medications, etc, and that the measure eventually used was the least restrictive alternative for patient safety. Ongoing evaluation
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LAW AND THE EMERGENCY NURSE/Lee and Gurney
for the patient who is physically or chemically restrained or secluded is also required. That ongoing evaluation includes determining whether the patient still needs to be in restraints and/or seclusion. To meet CMMS requirements, staff need to be directly educated, both initially and in an ongoing manner. In legal terms, restraint of patients could lead to claims of false imprisonment. According to civil law (as opposed to criminal law), false imprisonment can occur when a patient is restrained unless there is justification for restricting a patient’s free movement. In this light, the patient’s medical record should clearly document the patient’s behavior that warranted the restraints and the justification for the use of restraints or seclusion to protect the patient.
When restraints are used, it is required that documentation be provided in the medical record to the effect that less restrictive interventions have been “determined to be ineffective.” Because patients who are restrained cannot perform routine activities, they need fluids, food, and toileting assistance. A schedule of restraint release and evaluation of circulation and neurologic sensation, for example, is important to avoid complications from the restraints. Should you restrain the “difficult” patient described in the opening paragraph of this article? Perhaps, but only with evidence of potential harm to herself, only with documentation of the behavior that would let a reasonable person know she is in need of the restraints, and only if it is done with the least restriction possible. For example, if the patient is pulling at her intravenous line and it looks like she might interfere with an infusion that she needs, is there a way of restraining only the hand she is using to pull at the line? This is called a medical surgical restraint. If she tries to put her legs over the edge of the stretcher and seems to be trying to get out of bed, which means she would probably fall and injure herself, are rails or a Posey sufficient to keep her in bed? The interpretive guidelines specify that gerichairs and side rails are restraints but would be governed by the acute medical and surgical care standards.2
336
Instances may occur in which a patient like the one described might be distraught over a delusion that she is in a place that will harm her, and she may be intent on escaping. Paranoia argues for chemical restraints (antipsychotic or antianxiety medication) and/or physical restraints.
Ongoing evaluation for the patient who is physically or chemically restrained or secluded is also required. The issue of restraints is garnering more and more attention. I have heard of numerous situations in which there was not enough staff to ensure oversight of patients who would have been restrained years ago but now are not restrained and who became agitated and were injured or injured others (see article in this issue by Arthur and Bain). The key seems to be the following: 1. Obtain an order from a physician for restraints to be applied when they are needed, and then periodically thereafter, not on a prn order. The physician also needs to reevaluate the patient. Restraint and seclusion orders for behavior management only are time limited: 4 hours for adults (ages 18 and older), 2 hours for children ages 9 to 17 years, and 1 hour for children 8 years of age and younger)3 (see section [482.13][f ][3][ii][D] in reference 3). 2. Use the least restrictive means of keeping the patient safe (eg, if 2 restraints will suffice, do not use 4 restraints. If a Posey vest is enough to keep the patient in the bed, do not restrain limbs). 3. Document the very specific worrisome aspects of the patient’s behavior; document offering of fluids, food, and toileting; and document monitoring restraints to ensure they are not cutting off circulation or pressing on nerves (see the Clinical Notebook article by Diane Gurney in this issue for a caremap). 4. ED staff may want to try to take a more creative approach to the problem, perhaps by calling family in from the waiting room or even from home to sit with patients who would otherwise need restraints. Even patients coming in from nursing homes may have relatives at home who are willing to sit with them. The ED administrative staff could help with calls or could tap existing hospital volunteers to sit with patients.
JOURNAL OF EMERGENCY NURSING
28:4 August 2002
LAW AND THE EMERGENCY NURSE/Lee and Gurney
Nurses are in a difficult position. Their mandate to protect patients and their need to protect themselves from liability or injury sometimes conflict with a patient’s right to be free from restraint or seclusion. Ultimately, however, if nurses are seen as restraining a patient purely for convenience, they would be in violation of the Conditions of Participation. To ensure there is compliance, facilities that receive Medicare funding should closely read the Conditions of Participation and ensure that nurses and physicians are provided with continuing education so they are able to comply. REFERENCES 1. Health Care Financing Administration, US Department of Health and Human Services. Hospitals’ conditions of participation (428.13)(e)(2). Federal Register 64;36070 (July 2, 1999). 2. Health Care Financing Administration, US Department of Health and Human Services. Hospitals’ conditions of participation, introduction to Standards (e) and (f ). Federal Register 64:36070 (July 2, 1999). 3. Health Care Financing Administration, US Department of Health and Human Services: Hospitals’ conditions of participation, (482.13)(f )(3)(ii)(D). Federal Register 64:36070 (July 2, 1999).
August 2002 28:4
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The Legal Use of Restraints
Authors: Genell Lee, MSN, RN, JD, and Diane Gurney, RN, MS, CEN, Montgomery, Ala, and Hyannis, Mass Section Editor: Gail Pisarcik Lenehan, RN, EdD, FAAN
Genell Lee, Metro Birmingham Chapter, is Executive Officer, Alabama Board of Nursing, Montgomery, Ala; E-mail: [email protected]. Diane Gurney, Mayflower Chapter, is Trauma Coordinator and Educator, Emergency Center, Cape Cod Hospital, Hyannis, Mass. Reprints not available from the authors. J Emerg Nurs 2002;28:335-7. Copyright © 2002 by the Emergency Nurses Association. 0099-1767/2002 $35.00 + 0 18/9/126358 doi:10.1067/men.2002.126358
August 2002 28:4
I
t is the evening shift in a busy emergency department. A coworker called in sick, leaving the unit short staffed, and one of your patients constantly calls out. She is disoriented and repeatedly tells you that she wants you to take out her intravenous line and let her go home. A colleague suggests you restrain the patient. Should you? The process of restraining a patient who is judged to be confused or combative used to be fairly straightforward. You simply obtained a physician’s order (in an emergency, you did not even need an order until later) and restrained the patient. However, recent federal regulations have had an impact on the decisions and processes involved in restraining a patient. The Centers for Medicare & Medicaid Services (CMMS) (formerly the Health Care Financing Administration) published revised Conditions of Participation in July 1999.1 Facilities that receive Medicare funds are governed by these Conditions of Participation. CMMS standards state that patients have a right to be free from restraint or seclusion, and they prohibit the use of restraints for staff convenience, punishment of patients, or as a retaliatory measure. One key prohibition is that there should not be physician orders for prn or as-needed restraint or seclusion. When restraints are used, it is required that documentation be provided in the medical record to the effect that less restrictive interventions have been “determined to be ineffective.”1 The documentation at Cape Cod Hospital actually has a list of alternative measures that have been tried prior to resorting to restraint and or seclusion, such as orientation, modification of environment, diversional activities, having a family member sit with patient, medications, etc, and that the measure eventually used was the least restrictive alternative for patient safety. Ongoing evaluation
JOURNAL OF EMERGENCY NURSING
335
LAW AND THE EMERGENCY NURSE/Lee and Gurney
for the patient who is physically or chemically restrained or secluded is also required. That ongoing evaluation includes determining whether the patient still needs to be in restraints and/or seclusion. To meet CMMS requirements, staff need to be directly educated, both initially and in an ongoing manner. In legal terms, restraint of patients could lead to claims of false imprisonment. According to civil law (as opposed to criminal law), false imprisonment can occur when a patient is restrained unless there is justification for restricting a patient’s free movement. In this light, the patient’s medical record should clearly document the patient’s behavior that warranted the restraints and the justification for the use of restraints or seclusion to protect the patient.
When restraints are used, it is required that documentation be provided in the medical record to the effect that less restrictive interventions have been “determined to be ineffective.” Because patients who are restrained cannot perform routine activities, they need fluids, food, and toileting assistance. A schedule of restraint release and evaluation of circulation and neurologic sensation, for example, is important to avoid complications from the restraints. Should you restrain the “difficult” patient described in the opening paragraph of this article? Perhaps, but only with evidence of potential harm to herself, only with documentation of the behavior that would let a reasonable person know she is in need of the restraints, and only if it is done with the least restriction possible. For example, if the patient is pulling at her intravenous line and it looks like she might interfere with an infusion that she needs, is there a way of restraining only the hand she is using to pull at the line? This is called a medical surgical restraint. If she tries to put her legs over the edge of the stretcher and seems to be trying to get out of bed, which means she would probably fall and injure herself, are rails or a Posey sufficient to keep her in bed? The interpretive guidelines specify that gerichairs and side rails are restraints but would be governed by the acute medical and surgical care standards.2
336
Instances may occur in which a patient like the one described might be distraught over a delusion that she is in a place that will harm her, and she may be intent on escaping. Paranoia argues for chemical restraints (antipsychotic or antianxiety medication) and/or physical restraints.
Ongoing evaluation for the patient who is physically or chemically restrained or secluded is also required. The issue of restraints is garnering more and more attention. I have heard of numerous situations in which there was not enough staff to ensure oversight of patients who would have been restrained years ago but now are not restrained and who became agitated and were injured or injured others (see article in this issue by Arthur and Bain). The key seems to be the following: 1. Obtain an order from a physician for restraints to be applied when they are needed, and then periodically thereafter, not on a prn order. The physician also needs to reevaluate the patient. Restraint and seclusion orders for behavior management only are time limited: 4 hours for adults (ages 18 and older), 2 hours for children ages 9 to 17 years, and 1 hour for children 8 years of age and younger)3 (see section [482.13][f ][3][ii][D] in reference 3). 2. Use the least restrictive means of keeping the patient safe (eg, if 2 restraints will suffice, do not use 4 restraints. If a Posey vest is enough to keep the patient in the bed, do not restrain limbs). 3. Document the very specific worrisome aspects of the patient’s behavior; document offering of fluids, food, and toileting; and document monitoring restraints to ensure they are not cutting off circulation or pressing on nerves (see the Clinical Notebook article by Diane Gurney in this issue for a caremap). 4. ED staff may want to try to take a more creative approach to the problem, perhaps by calling family in from the waiting room or even from home to sit with patients who would otherwise need restraints. Even patients coming in from nursing homes may have relatives at home who are willing to sit with them. The ED administrative staff could help with calls or could tap existing hospital volunteers to sit with patients.
JOURNAL OF EMERGENCY NURSING
28:4 August 2002
LAW AND THE EMERGENCY NURSE/Lee and Gurney
Nurses are in a difficult position. Their mandate to protect patients and their need to protect themselves from liability or injury sometimes conflict with a patient’s right to be free from restraint or seclusion. Ultimately, however, if nurses are seen as restraining a patient purely for convenience, they would be in violation of the Conditions of Participation. To ensure there is compliance, facilities that receive Medicare funding should closely read the Conditions of Participation and ensure that nurses and physicians are provided with continuing education so they are able to comply. REFERENCES 1. Health Care Financing Administration, US Department of Health and Human Services. Hospitals’ conditions of participation (428.13)(e)(2). Federal Register 64;36070 (July 2, 1999). 2. Health Care Financing Administration, US Department of Health and Human Services. Hospitals’ conditions of participation, introduction to Standards (e) and (f ). Federal Register 64:36070 (July 2, 1999). 3. Health Care Financing Administration, US Department of Health and Human Services: Hospitals’ conditions of participation, (482.13)(f )(3)(ii)(D). Federal Register 64:36070 (July 2, 1999).
August 2002 28:4
JOURNAL OF EMERGENCY NURSING
337