Restraint Regulations and Elopement Alarms

The Restraint-Free Environment

Historically, restraints were commonly used in long-term care facilities to prevent falls or manage wandering. However, extensive research showed that restraints often cause more harm than good, leading to severe injuries, pressure ulcers, muscle atrophy, incontinence, depression, and even death from strangulation.

Today, federal laws (such as OBRA 1987) and New Hampshire state regulations mandate that facilities strive for a restraint-free environment. Residents have a fundamental right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience. Restraints may only be used as a last resort to treat the resident's medical symptoms, to ensure the physical safety of the resident or others, and only when less restrictive alternatives have failed.

Definitions of Restraints

There are two main categories of restraints:

1. Physical Restraints: Any manual method, 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. Examples: Vest restraints, wrist/ankle restraints, lap belts that the resident cannot undo, bed rails that keep the resident from getting out of bed, and specialized chairs (like Geri-chairs) if the tray table prevents the resident from standing up.
2. Chemical Restraints: Any drug used for discipline or convenience and not required to treat medical symptoms. Medications should only be used to treat specific diagnosed conditions (like a psychiatric disorder), not simply to sedate a wandering or restless resident.

Strict Regulations and Requirements

Because applying a restraint infringes on a resident's basic rights, the legal threshold for their use in New Hampshire is extremely high. Before a restraint can be applied, all of the following must occur:

• Medical Necessity: The restraint must be needed to treat medical symptoms or ensure immediate physical safety, not for staff convenience.
• Less Restrictive Alternatives: The facility must document that all less restrictive alternatives were tried and failed.
• Physician's Order: A physical restraint absolutely requires a written order from a physician or licensed independent practitioner. The order must specify the type of restraint, the medical reason, and how long it should be used.
• Informed Consent: The resident or their legal representative must be informed and provide consent.

A Licensed Nursing Assistant (LNA) cannot independently decide to apply a restraint. Doing so is considered false imprisonment and battery, which are grounds for termination, registry findings, and criminal charges.

Alternatives to Restraints

Before considering restraints, the interdisciplinary care team will implement alternatives. As an LNA, you play a vital role in utilizing these interventions:

• Addressing physical needs: Pain, hunger, thirst, or the need to use the bathroom often cause restlessness. Anticipating and meeting these needs promptly can resolve the behavior.
• Environmental changes: Using low beds with floor mats to minimize fall injuries. Enhancing lighting, reducing noise, and providing a calm environment.
• Activities and diversion: Meaningful activities, folding towels, listening to familiar music, or sitting near the nursing station for closer observation.
• Alarms: Bed and chair alarms alert staff when a resident attempts to stand up unassisted. While they do not physically restrict the resident, they allow staff to intervene quickly.

Care of the Restrained Resident

If a resident does have a physician order for a restraint, the LNA has strict monitoring and care responsibilities to prevent complications. These rules are heavily tested:

1. Check every 15 minutes: The restrained resident must be checked visually at least every 15 minutes. You must ensure the restraint is not too tight (you should be able to slide a flat hand between the restraint and the resident), that circulation is not impaired, and that the resident is safe and calm.
2. Release every 2 hours: At a minimum, the restraint must be removed every two hours for at least 10-15 minutes. During this release time, you must provide basic care:
   • Offer toileting assistance or change brief.
   • Offer food and fluids.
   • Reposition the resident.
   • Provide skin care and check for any signs of redness, friction, or breakdown.
   • Perform active or passive range-of-motion exercises.

Always document the 15-minute checks and the 2-hour releases precisely according to facility policy. If you notice any signs of poor circulation (e.g., pale, cold, or blue skin, or the resident complains of numbness or tingling), release the restraint immediately and notify the charge nurse.

Elopement Risks and Wanderguard Alarms

Elopement occurs when a resident who is cognitively impaired (such as having Alzheimer's disease or other dementias) leaves the facility or a safe area without staff knowledge. Elopement is a life-threatening emergency, particularly in New Hampshire where extreme weather conditions (such as winter freezing) pose immediate dangers.

To manage elopement risks without using physical restraints, facilities use specialized electronic safety systems, commonly known by brand names like Wanderguard.

• How they work: A small, watch-like transmitter is secured to the resident's wrist or ankle. If the resident approaches an exit door, the system may automatically lock the door or trigger a loud alarm at the exit and the nursing station.
• LNA's Role:
  • You must check the placement and function of the Wanderguard bracelet daily (often during morning care or bathing).
  • If the alarm sounds, you must respond immediately. Never assume it is a false alarm or that someone else will check it. Go directly to the door that triggered the alarm and secure the resident.
  • Ensure that visitors do not inadvertently let residents with Wanderguards slip out the door as they exit.

Preventing elopement is a team effort. Any staff member who sees a resident attempting to leave the facility must intervene gently, redirect the resident, and alert the nursing staff.