Physical Restraints

The Centers for Medicare & Medicaid Services (CMS) defines a physical restraint as “any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body.” (42 CFR 483.13(a)) When determining whether a device meets the definition of a physical restraint, the focus should be on the effect the device has on the resident, not the intent or reason behind the use of the device. Restraints may only be used to treat the resident’s medical symptoms upon the written order of a physician, except in the case of emergencies. (SOM, 2006)

Types of physical restraints include, but are not limited to leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions, and lap trays the resident cannot remove easily. Also included as restraints are facility practices that meet the definition of a restraint such as:

• Using side rails that keep a resident from voluntarily getting out of bed
• Tucking in or using Velcro to hold a sheet, fabric, or clothing tightly so that a resident’s movement is restricted
• Using devices in conjunction with a chair, such as trays, tables, bars or belts, that the resident cannot remove easily, that prevent the resident from rising
• Placing a resident in a chair that prevents a resident from rising
• Placing a chair or bed so close to a wall that the wall prevents the resident from rising or voluntarily getting out of bed (SOM, 2006)

The Resident Assessment Instrument (RAI) Manual offers guidance for the review of conditions commonly associated with restraint use:

• Problem Behavioral Symptoms
• Risk of Falls
• Conditions and Treatments (Resistance to Tubes or Mechanical Devices)
• ADL Self-Performance
• Confounding Problems Associated with Behavioral Symptoms (Delirium; Impaired Cognition; Impaired Communication; Unmet Psychosocial Needs; Sad or Anxious Mood; Resistance to Treatment, Medication, Nourishment;

The use of restraints not only violates resident’s rights to freedom and dignity, but has also been associated with higher rates of injury and injurious falls, precisely the condition that the restraints are designed to prevent. There are many negative effects and risks associated with restraint use that in some cases far outweigh any possible benefit of using them. Risks associated with using restraints are listed below:

• Strangulation
• Loss of muscle tone
• Decreased bone density (with greater susceptibility for fractures)
• Pressure sores
• Decreased mobility
• Depression
• Agitation
• Loss of dignity
• Incontinence
• Constipation
• Death

(RAI, Appendix C, p. 99)

Some barriers to restraint reduction/elimination include:

• Perception that physical restraints deter disruptive behaviors and wandering
• Perception that physical restraints prevent falls
• Perception that physical restraints are a safety device

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