NOTE: If only lawmakers paid the same attention to the increasing use of restraints in schools...
By Julie Appleby and Jack Gillum, USA TODAY
February 16, 2009
Diann Snyder has a simple rule at the long-term care home where she's director of nursing: Restraints are not an option.
"If you restrain a resident, you actually see some desperation," Snyder says. "They experience some anguish. You kind of break their spirit. They give up. "
When she joined the staff of the Thornwald Home in Carlisle, Pa., 15 years ago, the facility sometimes used physical restraints on the elderly residents to keep them in their chairs or from wandering the halls. Staff and family members believed restraints made the residents safer.
Snyder knew that wasn't correct. "Statistics have shown there have actually been deaths from (the use of) restraints," she says. "That is definitely far worse than if they fall."
Now, none of Thornwald's 83 residents are in restraints, reflecting both Snyder's efforts and a nationwide push to reduce the practice. Nursing homes immobilize 5.5% of their residents with physical restraints on average, about a quarter as many as they did in 1991, a USA TODAY analysis of nursing homes' self-reported data to Medicare shows.
Physical restraints — once widely used in nursing homes to prevent falls — are any device that inhibits a residents' movement or access to their body, according to the National Citizens' Coalition for Nursing Home Reform, a group that in part advocates reduced restraint use.
"In general, restraint use has gone down dramatically," says Mercedes Bern-Klug, an assistant professor in social work at the University of Iowa who studies nursing homes. "Now we need to be vigilant about the places where restraint use is much higher than average."
She says muscles atrophy, and residents become socially withdrawn if they are immobilized.
"It affects the ability to maintain relationships, which is at the core of what we are as humans," she says.
'The right to be free'
Bern-Klug and others credit the drop to a decades-long movement to "untie the elderly," which united patient advocates, nursing homes, government groups and private foundations.
U.S. law does not ban restraints, which can be used if there are documented medical reasons to do so. In 1987, Congress passed a law that granted nursing home residents "the right to be free" of restraints and barred their use for discipline or convenience.
Medicare says an average of 21.1% of residents were restrained daily in 1991. That dropped to 8.5% in 2003 and 5.5% in 2007, USA TODAY's analysis found. Among other findings from 2007, the most recent full-year set available:
• Physical restraints were used on 20% or more residents at 665 homes out of about 14,800 reviewed nationwide.
• Twenty-five states used restraints on 4% or fewer residents on average.
• State averages ranged from a low of 1.7% of nursing home residents in restraints in Alaska to a high of 11.8% in Louisiana. Restraint use also topped 10% in three other states: Arkansas, California and Oklahoma.
"We've made a major effort to reduce restraint use in the last couple of years," lowering it from about 20%, says Joe Donchess, executive director of the Louisiana Nursing Home Association. Homes in the state are working with a Medicare quality-improvement group.
The overall drop demonstrates "a commitment of all the people involved" — from state officials to advocates and home administrators, says Larry Minnix, president and CEO of the American Association of Homes and Services for the Aging, a trade group that represents non-profit homes.
Yet some researchers question whether the statistics accurately reflect what is going on because nursing homes themselves report the data to Medicare.
"Restraint use has gone down, but the caveat is that these data aren't audited. So no one knows whether they are right," says Charlene Harrington, a nursing home researcher at the University of California, San Francisco.
In addition, "very few facilities get cited" for overuse of restraints, says Patricia McGinnis of California Advocates for Nursing Home Reform, who adds regulators should be more vigilant.
Pennsylvania leads the way
Pennsylvania is among the states at the forefront of the no-restraint movement.
In 1996, Pennsylvania's nursing homes restrained nearly 29% of residents, says Susan Williamson, an assistant director in the state's health department.
State and U.S. officials, nursing home operators and patient advocates responded with an outreach effort that includes training programs at the nursing homes.
The voluntary program has reached 91% of the state's 723 nursing homes, and the restraint rate dropped to 2.8% in 2008, Williamson says.
Restraint use can go down if nursing homes prevent falls or lessen their severity with padded flooring and other methods. Better pain management can reduce agitation, another cause of restraint use, while efforts to boost companionship or provide activities can help residents with dementia, the national citizens coalition says.
At the Thornwald Home, staff members assess each resident and make needed changes, Snyder says. That can involve altering a medication that makes a resident dizzy or offering physical therapy to improve balance. Residents are given socks with non-skid soles. Chair seats have non-slip covers. Beds can be lowered and have special lips so residents won't slide off.
The key is "you have to educate, educate, educate," Snyder says. "Not only staff, but also residents, families and physicians."