5.4 Fall Prevention, Restraints & Restraint Alternatives

5.4 Fall Prevention, Restraints & Restraint Alternatives

Quick Answer: Falls are the leading cause of injury in long-term care. Key fall prevention interventions include keeping beds in the lowest locked position, answering call lights immediately, providing non-skid footwear, maintaining clutter-free pathways, and conducting proactive toileting rounds. A physical restraint is any device/method attached or adjacent to the body that restricts movement and cannot be easily removed by the resident. Restraints are strictly a measure of last resort, require a written time-limited physician order, and PRN orders are strictly prohibited. Restrained residents must be monitored every 15–30 minutes and released at least every 2 hours for a minimum of 10 minutes for ROM, toileting, hydration, and skin care. Restraint alternatives (low beds, floor mats, sensor alarms, purposeful rounding) must always be attempted first.

Maintaining a safe, therapeutic environment while upholding resident dignity, autonomy, and physical mobility is a cornerstone of nursing assistant practice. In long-term care and post-acute settings, accidental falls represent the leading cause of fatal and non-fatal injuries, including hip fractures, subdural hematomas, and debilitating loss of functional independence.

Historically, physical restraints were widely used under the mistaken assumption that tying residents to beds or chairs prevented falls. Modern clinical evidence and federal healthcare statutes have disproven this myth: restraints do not prevent falls and actually increase the incidence of severe injury and death. The Omnibus Budget Reconciliation Act of 1987 (OBRA '87) and the Centers for Medicare & Medicaid Services (CMS) strictly regulate restraint usage, establishing the resident's legal right to be free from physical or chemical restraints.

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1. Resident Fall Risk Factors: Intrinsic vs. Extrinsic

Fall prevention begins with a comprehensive understanding of why residents fall. Fall risks are categorized into intrinsic (resident-related) and extrinsic (environmental) factors.

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|                      RESIDENT FALL RISK TAXONOMY                            |
|                                                                             |
|   INTRINSIC FACTORS (Internal to Resident)                                  |
|   - Muscle weakness (sarcopenia) & unsteady gait / poor balance             |
|   - Orthostatic hypotension (blood pressure drop upon standing)             |
|   - Visual impairments (cataracts, glaucoma, macular degeneration)          |
|   - Cognitive deficits (Alzheimer's, dementia, delirium, poor safety awareness|
|   - Urinary urgency, frequency, and nocturia                                |
|   - Polypharmacy (sedatives, antihypertensives, diuretics, psychotropics)   |
|   - History of prior falls                                                  |
|                                                                             |
|   EXTRINSIC FACTORS (Environmental Hazards)                                 |
|   - Poor or inadequate lighting / harsh glare                               |
|   - Wet, slippery, or highly waxed floors                                   |
|   - Cluttered pathways, loose electric cords, throw rugs                    |
|   - Bed maintained at improper working height                               |
|   - Unlocked wheels on beds, wheelchairs, or commodes                       |
|   - Call light out of reach or unanswered call lights                       |
|   - Improper, loose, or slick footwear                                      |
|   - Damaged, poorly fitted canes or walkers                                 |
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2. Frontline CNA Fall Prevention Interventions

Certified Nursing Assistants execute the daily environmental controls and direct interventions that prevent resident falls:

1. Bed Safety & Wheel Locks:
   • Keep the resident's bed in its lowest position at all times (except when the nurse aide is actively performing bedside care at proper working height).
   • Ensure bed wheels are securely locked at all times.
   • Ensure wheels on wheelchairs, bedside commodes, and shower chairs are locked before initiating any transfer.
2. Call Light Accessibility & Prompt Response:
   • Place the call light signaling device directly within the resident's unaffected hand before leaving the room.
   • Answer call lights IMMEDIATELY: Toileting is one of the most common activities associated with resident falls, and a resident who waits for help will eventually stop waiting and get up alone. Treat an unanswered call light as an active fall risk rather than a customer-service problem.
3. Footwear Standards:
   • Ensure residents wear well-fitting, non-skid rubber-soled shoes or facility-approved non-skid socks whenever their feet touch the floor. Never allow residents to walk in bare feet, slick stockings, or ill-fitting backless slippers.
4. Environmental Clearance & Lighting:
   • Maintain clear, unobstructed pathways from the bed to the bathroom and doorway. Keep floor free of cords, trash cans, and personal items.
   • Ensure adequate lighting in rooms and hallways; leave nightlights illuminated in bathrooms.
5. Preventing Orthostatic Hypotension (The "Dangle" Protocol):
   • When assisting a resident from lying down to standing, always have them sit on the edge of the bed with feet flat on the floor ("dangle") for 1 to 2 minutes before standing.
   • Ask if they feel dizzy or lightheaded; observe for pale skin or diaphoresis.
6. Proactive Purposeful Hourly Rounding (The "4 Ps"):
   • Conduct scheduled rounds every 1 to 2 hours addressing:
     • Pain: Assess comfort level and report pain to the nurse.
     • Position: Assist with repositioning and comfort alignment.
     • Potty: Offer scheduled assistance with toileting.
     • Possessions: Place water, telephone, eyeglasses, tissues, and call light within easy reach.

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3. Restraint Definitions: Physical vs. Chemical

Federal and state regulations clearly define restraints to prevent unauthorized staff practices that restrict resident freedom.

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|                        TYPES OF RESTRAINTS                                  |
|                                                                             |
|   PHYSICAL RESTRAINT                                                        |
|   - Any manual method, physical/mechanical device, material, or equipment   |
|     attached or adjacent to the resident's body that the individual         |
|     CANNOT EASILY REMOVE and which restricts freedom of movement.           |
|                                                                             |
|   CHEMICAL RESTRAINT                                                        |
|   - Any psychoactive medication or drug used for the CONVENIENCE OF STAFF   |
|     or to DISCIPLINE a resident, rather than to treat specific medical/     |
|     psychiatric symptoms, which sedates or restricts movement.              |
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Clinical Examples of Physical Restraints

• Vest or Jacket Restraints: Applied to chest and tied to bed frame or chair.
• Belt / Waist Restraints: Secured around waist to prevent rising from wheelchair or bed.
• Limb Restraints (Wrist / Ankle): Secured around extremities to prevent pulling out vital lines (endotracheal tubes, IVs, Foley catheters).
• Mitt Restraints: Hand coverings that prevent finger grasping; classified as a restraint if tied to bed frame or so bulky resident cannot open doors/remove them.
• All Four Bed Side Rails Raised: When all side rails are elevated, preventing an ambulatory resident from voluntarily exiting the bed, the bed rails function legally as a physical restraint.
• Geri-Chair with Fixed Lap Tray: Placing a resident in a geriatric reclining chair with an attached tray table that the resident cannot independently remove is legally a physical restraint.
• Tightly Tucked Bed Sheets: Tucking top sheets and blankets so tightly around a resident that they cannot move their extremities or roll over.

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4. Adverse Physical & Psychological Complications of Restraints

Immobilizing a human body produces severe, systemic physiological deterioration and profound psychological trauma:

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|                    COMPLICATIONS OF RESTRAINT USAGE                         |
|                                                                             |
|   PHYSICAL ADVERSE EFFECTS:                                                 |
|   - Strangulation and fatal positional asphyxiation                         |
|   - Pressure injuries from localized pressure, friction, and shear          |
|   - Joint contractures and progressive muscle atrophy (loss of strength)    |
|   - Bone demineralization and osteoporosis from lack of weight bearing      |
|   - Deep Vein Thrombosis (DVT) and fatal Pulmonary Embolism (PE)            |
|   - Constipation, fecal impaction, and severe urinary incontinence          |
|   - Hypostatic pneumonia from respiratory hypoventilation                   |
|   - Nerve compression and peripheral circulatory impairment                 |
|                                                                             |
|   PSYCHOSOCIAL ADVERSE EFFECTS:                                             |
|   - Loss of personal dignity, self-esteem, and autonomy                     |
|   - Severe agitation, panic, terror, and combativeness                      |
|   - Profound depression, social withdrawal, and regressive behaviors        |
|   - Acute delirium and worsening disorientation                             |
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5. Federal OBRA '87 & CMS Restraint Regulations

Under federal law (OBRA '87) and CMS conditions of participation, restraints may only be used as an absolute measure of last resort when all less restrictive alternatives have been attempted, documented, and proven ineffective, and the resident presents an immediate, imminent physical danger to self or others.

Mandatory Regulatory Requirements

1. Physician's Written Order: Restraints require a written, time-limited order from a licensed physician or authorized advance practice provider stating the specific medical symptom, specific restraint type, anatomical location, and exact duration.
2. PRN Orders Strictly Prohibited: Restraint orders CANNOT be written on a PRN (as-needed) basis. Standing or "as-needed" restraint orders are strictly illegal.
3. Prohibition of Staff Convenience: Restraints can NEVER be used for staff convenience, punishment, discipline, or to compensate for staff shortages.
4. Informed Consent: The resident or their legal healthcare surrogate must be informed of the risks and benefits and give formal informed consent prior to application.

Application and Care Protocol

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6. Restraint Alternatives (Person-Centered Safety)

Healthcare facilities in South Carolina strive for a restraint-free environment by implementing proactive, person-centered restraint alternatives:

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|                     EFFECTIVE RESTRAINT ALTERNATIVES                        |
|                                                                             |
|   [ENVIRONMENTAL MODIFICATIONS]                                             |
|   - Low-low beds positioned inches from the floor                           |
|   - Beveled shock-absorbing floor mats placed beside bed                    |
|   - Electronic bed, chair, and floor pressure-sensor alarms                 |
|   - Soft, indirect lighting and soothing, quiet environments                |
|                                                                             |
|   [POSTURAL & POSITIONING AIDS]                                             |
|   - Body pillows, wedge cushions, and concave pressure-redistribution beds  |
|   - Reclining chairs with ergonomic lateral torso supports                  |
|                                                                             |
|   [PSYCHOSOCIAL & BEHAVIORAL ENGAGEMENT]                                    |
|   - Placing restless residents near the central nurses' station             |
|   - Purposeful activities (folding towels, sorting socks, music therapy)   |
|   - Frequent, scheduled toileting and hydration rounds (hourly rounding)    |
|   - Involving family members and volunteer companions (sitters)             |
|   - Ensuring corrective eyeglasses and clean hearing aids are worn          |
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