5.4 Resident Safety and Restraints

Resident Safety and Restraints

Quick Answer: Fall prevention is built on a simple bundle: low bed, call light within reach, non-skid footwear, clear path, adequate lighting, and fast call-light response. Restraints (physical OR chemical) require a time-limited physician order, the least restrictive device, monitoring at least every 15 minutes, and release every 2 hours for ROM, toileting, and food/fluid. Per OBRA and CMS, a restraint can never be used for staff convenience.

Why Falls Matter

Falls are the most common adverse event in U.S. nursing homes. The CDC reports that 1 in 4 older adults fall each year, and about half of long-term care residents fall annually - often more than once. Roughly 20-30% of falls cause moderate to severe injury, including hip fractures and traumatic brain injuries.

Key Fall Risk Factors

The Fall-Prevention Bundle

The NC NNAAP skills test rewards a complete bundle. CNAs should:

• Keep the bed in the LOWEST position with the brakes locked whenever the resident is in it.
• Place the call light within reach on the unaffected (strong) side for residents with hemiparesis.
• Apply non-skid footwear (rubber-soled slippers or shoes) before any transfer - never bare feet or stockings alone.
• Keep the path between bed and bathroom clear: cords, IV poles, side tables, throw rugs out of the way.
• Provide adequate lighting, including night lights.
• Answer call lights promptly - a 10-second response prevents the self-transfer that becomes a fall.
• Toilet on a schedule every 2 hours for at-risk residents.
• Use chair and bed alarms as ordered (audible alarms when the resident attempts to rise).
• Mark high-risk residents per facility policy (yellow blanket, yellow socks, yellow door sign).

Restraint Alternatives Come FIRST

CMS and the Omnibus Budget Reconciliation Act of 1987 (OBRA) require facilities to attempt and document restraint alternatives before requesting a restraint order. Alternatives include:

• Diversion: activities, music, puzzles, sorting tasks
• Hourly rounding for the 4 Ps - pain, potty, position, possessions
• Family presence or one-to-one observation (sitter) for high-risk residents
• Low beds or floor mats next to the bed
• Wedge cushions or pommel cushions instead of lap belts
• Pressure-sensitive alarms (chair, bed, wander) - used with caution; alarms can increase agitation
• Environmental adjustments: clear path, locked wheels, dim quiet room at night
• Toileting schedules to reduce urgency-driven self-transfers

Restraints (When They Are Used)

Definitions

• Physical restraint - any manual method, device, or equipment attached to the resident's body that the resident cannot easily remove and that restricts freedom of movement or normal access to the body. Includes wrist restraints, vests, lap belts the resident cannot release, side rails when used to keep the resident in bed, and a chair that prevents rising.
• Chemical restraint - any medication used to manage behavior, restrict movement, or for staff convenience, when not part of the resident's regular medical treatment.

OBRA / CMS / Joint Commission Rules

1. Restraints require a physician (or licensed independent practitioner) order that specifies the type, the clinical justification, and a time limit.
2. PRN ('as needed') restraint orders are prohibited.
3. The Joint Commission's behavioral health rule on time-limited orders: adults 4 hours, adolescents 9-17 years 2 hours, children under 9 1 hour - re-evaluation is required for renewal.
4. The least restrictive device that protects the resident must be selected.
5. The resident or surrogate must be informed of the reason and risks.
6. Restraints can never be used:
   • For staff convenience
   • As discipline or punishment
   • As a substitute for adequate staffing

CNA Monitoring Requirements

Once a restraint is applied:

Why Restraints Are Dangerous

Restraints can directly cause death and injury:

• Positional asphyxia when the resident slides under a vest restraint and cannot breathe
• Strangulation by the strap or by entrapment between mattress and rail
• Pressure injuries and nerve damage from prolonged immobility
• Increased agitation, confusion, and depression
• Loss of muscle mass, contractures, deconditioning
• Incontinence and constipation from inability to reach the toilet

North Carolina Specifics

North Carolina nursing facilities follow the federal OBRA restraint rules through 42 CFR 483.10 and the state's implementing regulations under the NC Department of Health and Human Services. The state surveyor cites facilities for any restraint applied without a current physician order, for missing 15-minute checks, or for missed 2-hour releases.