Nursing Home Does Not Use Restraints - Should we be worried?

While restraints are usually not acceptable, if a doctor determines that they are needed, there maybe a roundabout to their use at the facility. While I do not know how each state rules on these matters, I know that here there is a work around if necessary to prevent injury and to reduce legal action against ALF for such issues. Check with his primary care doctor and seek legal advice to protect your dad.

Ask the facility if they have a Posey bed. It kind of looks like a playpen over the bed. Zippers and flaps on outside of bed. He can't unzipped. He is enclosed but not restrained. He can't crawl out.

Perhaps you can get a lift to get your dad out of bed and into the chair and care for him at home longer? One of my neighbors has one, he fell off a ladder and has no use of his legs.. My neighbors are in their 70's... My Grandparents were here til the end and on hospice. GP had lots of equipment. If I recall once on hospice they took care of providing the equipment.

Just by way of illustration, here is a section from the relevant legislation for Illinois (I picked Illinois at random) -
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 (210 ILCS 45/2-106) (from Ch. 111 1/2, par. 4152-106) 
    Sec. 2-106. (a) For purposes of this Act, (i) a physical restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to a resident's body that the resident cannot remove easily and restricts freedom of movement or normal access to one's body. Devices used for positioning, including but not limited to bed rails, gait belts, and cushions, shall not be considered to be restraints for purposes of this Section; (ii) a chemical restraint is any drug used for discipline or convenience and not required to treat medical symptoms. The Department shall by rule, designate certain devices as restraints, including at least all those devices which have been determined to be restraints by the United States Department of Health and Human Services in interpretive guidelines issued for the purposes of administering Titles XVIII and XIX of the Social Security Act. 
    (b) Neither restraints nor confinements shall be employed for the purpose of punishment or for the convenience of any facility personnel. No restraints or confinements shall be employed except as ordered by a physician who documents the need for such restraints or confinements in the resident's clinical record. 
    (c) A restraint may be used only with the informed consent of the resident, the resident's guardian, or other authorized representative. A restraint may be used only for specific periods, if it is the least restrictive means necessary to attain and maintain the resident's highest practicable physical, mental or psychosocial well-being, including brief periods of time to provide necessary life-saving treatment. A restraint may be used only after consultation with appropriate health professionals, such as occupational or physical therapists, and a trial of less restrictive measures has led to the determination that the use of less restrictive measures would not attain or maintain the resident's highest practicable physical, mental or psychosocial well-being. However, if the resident needs emergency care, restraints may be used for brief periods to permit medical treatment to proceed unless the facility has notice that the resident has previously made a valid refusal of the treatment in question.
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What you'd need to find out next is how the NH goes about the correct procedure 😕

As your father is already accustomed to his own bed with his own full rails (presumably professionally fitted, and with cushioned bumpers?) this should go with him to the NH; and there should be a formal process for the NH to apply for permission to use these "restraints" in the patient's best interest.

The whole bureaucratic can of worms will have a formal, legal label in your state/county. In the UK it is referred to as "Deprivation of Liberty Safeguards," or DoLS for short; but every jurisdiction has its equivalent. Try Googling "legal use of restraints in [name of state] Nursing Homes" and see what you can find out. Then it will be a question of working with the NH to make sure they have this all set up before your father is admitted.

It goes roughly like this:

1. Risk identified and assessed.
2. Solution devised, deprivation of liberty identified.
3. Formal application for "DoL" made to safeguarding authority.
4. Permission granted by authority, with conditions. Or refused, if they don't agree that the proposed solution meets requirements. The solution must be:

- in the person's best interests
- necessary
- proportionate
- kept under review

lower bed as close to ground as possible. find a mattress or something to help cushion the fall.

Or find a night stand or something and place it as close to bed as possible.

and go to home depot or lowes and find pipe insulators. or pool noodles and cut and place on bed rails. use duct tape to hold insulators in place (not dad)if you feel it is necessary.

pipe insulation is pretty cheap and so are pool noodles. pool noodles has colors, so it may be prettier to look at.

Restraints for a long term facility are not only inhumane but can lead to injury, more falls and death. Full bed rails do not prevent falls

My BIL is a hospice Chaplin and regularly, before COVID, visited nursing homes. He told us that falls are a fact of life in facilities for the aged. Old people will fall, you can do all you can to protect them but they will fall.

I think restrainting is illegal many states. Ik it is heart breaking and it can be very upsetting situation. You're in my prayers.

Imho, restraints are not used because of potential injury. Prayers sent.

Restraints are against the law in many if not all states. What differs is "What is a restraint?"

In some states a restraint is anything that could prevent a patient out of or off of whatever they are on/in ie chair, bed . If fact in some states or large cities
geri-chairs are considered a restraint if they are even used, in others only if it is reclined, and still others any use is o.k.

I am not up on the laws but I have heard that restraints are NOT allowed in many facilities. Why? I don't know - makes no sense to me with the needs of these patients. I am for restraints in certain cases but I am not sure.

Nursing home are able now to put the bed lower to the ground, and have a mat on the floor to set off the alarm. Talk to the boss person as you have to give them the ok to do this. If they can’t help go to someone higher. Your father has a right to be safe. God bless.

We have been having problems with my Mom getting up at night and falling. Her memory care facility , which also does not use restraints, cranked her bed down to the lowest level and since she can’t stand without assistance she usually just rolls onto the floor. They have mats put down to cushion her. So far so good. I was told they can also put her mattress on the floor if it continues to be a problem.

Also, the rooms have motion sensors so if the staff detects unusual movement in her room at night an aid is sent to check it out.

Almost all residential facilities have gone away from restraints since there are a lot of issues with restraints: need for a lot of eyes on supervision, need to offer fluids and potty every 2 hours, and it doesn't always work keep folks from falling. Instead, facilities put people on "falls precaution" with beds at lowest height, thick mats placed on floor next to beds, checking on folks more often,,,

Sadly, because of lawsuits, the use of restraints like full bed rails are not used. If a patient has mats, lowered bed, and concave mattress, there is still risk. They could land awkwardly or end up with a greater risk of aspiration pneumonia. Even without the Covid situation, staffing can be difficult, particularly third shift in the middle of the night. Until there are lawsuits because restraints weren't used, here we are. Neither situation is without risk. My mother sustained two falls due to this. Luckily in both cases, she didn't break anything. Often, if a patient who is particularly known for being an escapist artist are placed in a room near the nurse's station where they can be observed more continuously. You could ask about that. If your loved one is on hospice, it can be a sticky situation if they do fall and an x-ray is taken. When this happened with mom (who was on an independent hospice inside a nursing home) there was some pushback about the x-ray from hospice who felt it shouldn't have been done. Wow! Why wouldn't you? These decisions as your loved ones near life's end are impossibly difficult and I found myself choosing between the lesser of two evils. Just know that you will make the best decision for the moment you are in and that you musn't be too hard on yourself. Your father could fall at home, and will fall out of bed in facility without restraints. There is risk in either place. At home, you could try what they would do in facility (pads, lowering the bed, etc) and he would get one on one care. In facility, they will provide him attention, but it certainly won't be one on one 24/7 and they are at the mercy of who they share a room with. When my parents each spent the last few months in facility, I visited as often as possible to fill in the gaps in care. There were gaps. They passed away before Covid, but with Covid happening now, I would wonder how well they would fair without my ability to visit and advocate. This is a consideration for you. Take care.

My Dad has Parkinson’s and is fairly weak. He is allowed to have the short “half” rails (that run from the top of the bed to between his shoulder and elbow). It is allowed because he needs them in order to turn when he’s in bed.

That is about the only legitimate way to get permission for them anymore.

After hip surgery, upon returning home from a rehab center, mom kept falling out of bed. She never had before, I can only assume it was the anesthesia she was shaking off. Or the pain meds. Anyway..

She BEGGED me to buy her guardrails and I kind of fought her on them-they seemed more dangerous, but I hit Amazon and the next am there they were (am I the only person who feels slightly creeped out that you can order something and get it before you even have time to regret your purchase?)

ANYHOW-the rails came, I went right up and installed them. That night she slid down in between the rails and the bed and was stuck.

Rails came down less than 24 hours after they were installed.

We took her bedskirt off (not an issue in NH's) and lowered her bed as far as possible and had her PT work with her specifically on safely getting up. IF she 'fell' it was more of a gentle slide to the ground. We didn't use pads, there was no room.

If she were on a mattress on the floor---not one of us 'kids' could deal with her care...we're 57-66 yo and sore knees and backs won't allow that.

You should be worried that with no bed rails he will fall be hurt and die.

If he is already on Hospice Care, if at all possible, you should continue with the Live In until he dies.
No matter how great a Nursing Home seems to you, your Dad will probably be miserable, depressed, scared and sad.
My Grandmother lasted 1 month.

If it were my Dad, I would continue letting him stay where he is, where he will be the safest.

I volunteered through a Hospice at a locked memory care unit. They had special beds that literally went all of the way to the floor. Most standard hospital beds can be lowered and should be. Also, sensored mats on either side of the bed to alert staff should they fall out. Never have side rails up. People have done more than break bones getting caught...patients have accidently hung themselves. Restraints are against the law in most states now. I would advise against nets above them. A determined patient could pull that done and get it wrapped around themselves. In my first year nursing, we had an alcoholic patient in locked leather restraints. My colleague was dealing with a screaming patient in the next room. Our 'restrained' patient walked into that room, dragging a broken IV bottle (yes, glass in the old days) and handing her the leather restraints! "here, I think you need these".
Also, determine if the facility is using chemical restraints as in heavy sedatives. Not a good solution ever.

when my dad first went into NH they had rails, but due to the change in laws (I think someone got a leg or arm stuck and it broke) they now are not allowed to use them as they are considered restraints......what they did for my father was to put the bed as far down close to the floor and then they put thick mats down on both sides of the bed on the floor, that way if he fell out of bed (which he did only one or two times) they won't get hurt.  Ask the nursing home you are considering if they lower the beds and put mats down.  Also if they know he might try to be an "escape artist" out of the chair they will keep him close to the nursing station to keep an eye on him, and the bed can be lowered when he is in it.  Wishing you luck on this issue.

I have limited experience with nursing homes but the ones we interviewed when placing MIL, they indicated that in her state it was illegal to restrain the patient. They were allowed to have a bed or chair alarm but no rails. So there may be no solution to your problem.

Hi Marie,

I work in a nursing home in PT rehab and hope my post will be helpful.

About full length bedrails, they are not used in nursing homes due to evidence of increased deaths and entrapments associated with their use. This is a very real danger. About alarms, evidence has been that they do not effectively reduce falls. Hard to believe, but true.

Restraining nursing home residents is not allowed unless deemed medically necessary and then only with doctor's orders. Many facilities are going "restraint free" so what you are encountering is not unusual. That said, there are other ways to increase safety if someone were to attempt getting up (some of which may require doctor's orders):
-- low bed near floor
-- padded mats at bedside
-- scoop mattresses with built up sides
-- moving the resident's room closer to the nurse's station
-- out-of-bed schedule that gives the patient position changes and allows for social interaction
-- activities to address restlessness and boredom
-- medical management and nursing interventions that will address restless associated with pain and discomfort

You should have this conversation with any facility you are considering and do independent checking of their safety record. Every facility has a yearly survey and rating from the Centers for Medicare and Medicare Services (CMS) that is available online. Each facility is required to display and make available their yearly survey. You can ask to see it.

Unfortunately, there is never a completely fool-proof method of preventing falls, especially as one's physical and cognitive impairments decrease their safety.

It's not an easy decision to make, but many families find that caring for a loved one with an advanced degenerative medical condition is more than they are equipped to handle. Best of luck in your search for placement of your father!

If it is a well-rated nursing home, they should know how to take care of a resident like your Dad. You can discuss it with them before you make your decision.

Im not sure about the negatives of full rails but I do know my dad and granddad fell in every family without them. Bruised from head to toe.

There are beds that go to within inches of the floor. Pads and alarms that can trigger unusual movements.
I don't like restrints or full rails because going over them is 😥.
If there is an iv, feeding tube , catheter then weigh risk / benefits

What type of facility?
if assisted most states won’t allow
if memory care they do

I know bed rails look safer but these are now considered restraints as everyone has said.

The biggest problem was
climbing OVER the rails & then falling.

Floor-lowered beds are used instead. Often placed against one wall with a 'crash mat' on other side.

I'd look at that. Hospice hopefully can provide this bed type.

I've seen situations where the bed is set lower to the ground and a mat is put beside the bed to cushion a fall. In a rehab hospital, I saw a net enclosing the bed. There was a slit on the side, so it wouldn't have kept me from getting out of the bed. Ask them what the plan is to prevent falls. Restraints are illegal.

Like others have said, they aren't allowed to use restraints. Staff are supposed to call you every time LO falls even if not injured. They are also then supposed to tell you of the plan to prevent it from happening again.

I know that hearing about a fall after-the-fact doesnt ease worries about falls and injuries, but it does give you a way to monitor safety.

Ask about their falls and injury reports to get an idea of their safety record. You certainly don't want to see a high number of falls and injuries, but you also dont want to see absolute zero. If it's 0, most likely they are doctoring their stats, because unfortunately, falls arent 100% preventable without restraints.

My dad has fallen out of bed at most rehabs he's been in. Luckily, he never got hurt. He tends to fall more in placement than he does at home. THe plan to fix things for him is usually to put the bed down as low as it can go and put mats on the floor when in bed.