Antipsychotic medications have been used as a form of chemical restraint in many nursing homes, with some reporting as high as 37% of residents.  These drugs are often used in nursing homes to make residents more calm and easier to handle. This type of chemical restraint is often the result of understaffing and not enough training.   When prescribed to patients that don’t need them, they can have a long list of side effects, which include agitation, fatigue, and loss of awareness and speech.

An alternative to chemical restraint is redirection, but critics say it can be time consuming. When a patient becomes agitated, instead of giving that patient a drug which will make them become drooling, incontinent, or out of it, the nurse or aide can redirect the patient. This involves finding out about the patient, what they liked, what they used to do. In many cases, a patient becomes agitated because they are in unfamiliar surroundings and cannot do things that they have done all their lives, like take walks, or sleep in. It can be helpful to learn more about a patient than simply their medical history because it can allow caregivers to form a bond with the patient which can help them feel familiar. Utilizing permanent staff for residents is a key part of building trust with that resident. Unfortunately, permanent staff requires that staff stay at a facility, and many homes have high turnover rates because of their working and operating conditions.

Critics say that in addition to being time consuming and sometimes impossible, taking time to redirect residents and forge bonds with them is simply not feasible or practical. In an industry where costs are constantly being cut, with Medicare and Medicaid being reduced at every turn, staff are decreasing, budgets for activities are decreasing, and there’s been a direct connection to federal cuts and the increase of these medications.

Overmedication of residents is a common occurrence because the systems don’t encourage caregivers to take time with residents. To have a nursing home where chemical restraints aren’t used unless necessary requires a timely, if not necessarily costly, overhaul of the entire home. The system that’s in place isn’t friendly to these changes, and until caregivers have the time to spend with residents, chemical restraint is going to be an accepted if hushed practice in nursing homes across the globe.

See articles here and here.

The Hartford Courant had a great editorial recently about the off label use of antipsychotics in nursing homes.  Below are excerpts.

Antipsychotic drugs are prescribed too frequently in Connecticut nursing homes to keep patients who have dementia or mental illness under control.

Lisa Chedekel of the nonprofit Connecticut Health Investigative Team has reported that some nursing homes in this state significantly exceed the national rate of administering such drugs to long-stay residents. At some facilities, the rate is more than double the already high state average. At one nursing home, 68 percent of long-stay residents were getting antipsychotics.

Antipsychotic drugs are supposed to be given only to patients diagnosed as having a psychosis or related condition. But in many nursing homes, they are prescribed for those who are difficult to manage, regardless of whether there’s a diagnosis of a mental illness.

 

That’s not good for patients, and ought to be curbed. The U.S. Health and Human Services Department has urged taking action against inappropriate prescription. The state Department of Public Health is trying to develop ways to reduce the use of antipsychotic medications.

Critics say that nursing homes are tempted to overmedicate because agitated patients are easier to deal with when sedated. But there can be serious, perhaps fatal, side effects to giving these drugs to elderly people with dementia.

Many residents of long-term-care facilities are neither elderly nor frail, but mentally ill. In 1995, the state closed two of its three mental institutions — Fairfield Hills and Norwich State Hospital — and some residents ended up in nursing homes. They may need to be treated with antipsychotic drugs. Still, that doesn’t excuse prescribing medication without a proper diagnosis, as some nursing homes do. That must stop.

Increasing staff and training has been suggested as a way to lower the need to use medication — but those are expensive, and for facilities that rely on Medicaid reimbursement, the funding may not be adequate. This problem, as so many in health care, is linked to money.

Long-term solutions to overmedication should involve alternative ways to care for those with mental illness, perhaps in supervised group homes.

 

The below information comes from an interesting article published on the Senior Homes Blog.  A new program hopes to reduce the use of “chemical restraints” in nursing homes.   CMS has launched a program, the Partnership to Improve Dementia Care, that is striving to reduce the use of these drugs and improve the care and overall quality of life for these residents. This campaign will do this through the education of nursing home staff, as well as the general public. The program will also provide training to improve the quality of care, print information on the website Nursing Home Compare about the use of the drugs, and educate and inform nursing home about alternatives to chemical restrains.

Previously, nursing home facilities relied primary on out-dated physical restraints, such as lap belts and bed bars, to restrict the movement of their residents.   However, restraints are only to be used when they are absolutely necessary and doctor-ordered so nursing homes are turning to “chemical restraints” as a substitute.  We see this in many of our nursing home cases.  Residents so doped up they can’t move or talk.

The Center for Medicare and Medicaid Services reported that an appalling 17 percent of dementia residents in skilled nursing home facilities are being over medicated with unnecessary drugs that can alter their normal behavior and mood in an attempt to keep them sedated and restrained.
CMS is taking steps to fight this unneeded, overuse of restricting drugs in nursing homes.

Sadly, the potential benefits of this program may never be fully reached due to several obstacles.  The American Psychiatric Association reported that they view alternatives to chemical restrains as weaker options.  Also Matt Bennett, senior vice president of Pharmaceutical Research and Manufacturers of America, voiced his concerns that the program will, “limit access to necessary pharmacological treatment.” Ironically, both of these concerned parties have heavy ties to the pharmaceutical business.  Knowing this, one would hope that these parties are speaking out of genuine concern for how this program will effect resident rather than simply because they are afraid it will hurt the pharmacological business and profits.

It is a tragic situation when profits, rather than quality of care, are made the main priority.

Two articles reported on a groundbreaking study from the Journal of the American Medical Association that has proved the use of restrains to be unnecessary in nursing homes.  According to a study, nursing homes that simply increased staff training and provided supportive equipment had a lessened need for the use of restraints.   "Nursing home care does not necessitate the administration of physical restraints, as demonstrated by our own epidemiological research," the authors of the study said. "We found pronounced center variation, with best-practice centers applying very few physical restraints.”

In the study the experimental group received an intervention where they were trained and taught alternative methods to care for fall prone residents other than simply belting them down to their bed or wheelchair. The study proved the alternative intervention to be just as effective at preventing falls and fall related fractures as the use of restraints. 

It is obvious that there are much better alternatives than simply tying down a resident yet, today restraints are still being used on more than 20% of residents in U.S. nursing homes. Why is there still such a high prevalence of restrains when more effective, humane methods have been proved to be just as effective? The additional cost of the intervention could be the reason more nursing homes are not participating. Sadly, many nursing homes are of the mentality that if the method they have works why spend unnecessary funds on an alternative method, even if the new method could greatly improve their residents’ quality of life.

See articles at MSN Health and Nurses.com.  Find Study at JAMA. 2012;307(20):2177-2184. doi:10.1001/jama.2012.4517 orhere.

The Herald Sun reported the tragic death of a female resident who died while tied to a toilet for two hours at a Victorian nursing home.  Widow Gwendoline Gleeson was put in a restraining belt and placed on a toilet at Barrabill House nursing home in Seymour in August last year and forgotten by staff who later found her dead.

There was no physical reason why the nylon restraining belt was used on Mrs Gleeson other than it being used to free up staff who would otherwise have to supervise her.  Mrs Gleeson’s care plan contained no family authorisation for the restraints and ordered she be supervised during toileting.

After being seen by a doctor on the morning of her death, Mrs Gleeson was placed on the toilet about 2.45pm by staff from the morning shift. A restraining belt was attached to hand bars beside the toilet and around her waist.   A staff shift change occurred at 3pm and the afternoon shift, who were apparently unaware of Mrs Gleeson’s whereabouts, did not discover her until 4.40pm.

 

Nurse.com promoted Healthcare Quality Strategies Inc.’s award to Christian Health Care Center in Wyckoff, N.J.for meeting "targeted improvement rates" established by Centers for Medicare & Medicaid Services for physical-restraint reduction.   Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body. Something as simple as a seat belt is considered a restraint if the resident doesn’t have the cognitive and physical ability to remove it.   The physical consequences of restraints include limiting the residents’ ability to walk, eat, change position, use the toilet and interact with others. These restrictions can cause injuries, falls, incontinence, poor nutrition, dehydration and limited movement. Restraints can cause psychological issues as well, such as agitation, verbal outbursts and depression.

Healthcare Quality Strategies is the Medicare-designated quality-improvement organization for New Jersey. Twenty New Jersey nursing homes with restraint rates above 6% participated in the initiative, which was rolled out in 2008. The goal was to achieve a 20% improvement rate. CHCC reduced its use of restraints from 8% to 1.6% by the conclusion of the project in the third quarter of 2010.   CHCC’s goal is to apply physical restraints only when the need for the restraint clearly outweighs the risks and the resident’s right to be restraint free.
 

Several strategies were used to achieve significant reduction in the use of restraints. First, staff needed to develop a philosophy of restraint-free care and individualized care plans.

Another strategy in reducing the use of restraints is to find alternatives. Nursing staff utilized bed and chair alarms, and other tools, such as low beds and mattresses on the floor, padded underwear, treaded socks and wrist bands to identify at-risk patients. Nursing staff also did frequent rounding on the residents regarding "the four Ps," pain, potty, positioning and personal needs. Patient-to-aide ratio also was examined, and a six-to-one ratio, along with consistent staff assignments, improves outcomes.

 

Harry Griph Sr. was expected to die. The 75-year-old retired phone company worker was in an assisted living facility as a hospice patient. The prognosis was grim: his chronic diseases and functional impairments indicated he was very near the end of life.

The New York Times reports that a staff member found him dead on Christmas morning. But Griph hadn’t died of natural causes. His neck was trapped between the bed rail and the mattress. He had died of suffocation.

Griph’s three children and his estate sued the nursing home where he died, the hospice provider, the maker of the bed and the vendor that supplied the bed. All but the assisted living facility have settled. A lawsuit alleging negligence against the facility continues.

David Perecman, of The Perecman Firm, P.L.L.C. in New York City, does not represent the Griph’s children or estate, but has handled numerous nursing home abuse cases, representing many families whose loved ones have been killed or injured. "A death in a nursing home–any death, really, especially one that was so clearly preventable–has a huge impact on the family and is not acceptable."

Disregarded Warnings

A spokesperson for the facility told the Times that the care provided Griph was adequate, despite the fact that the U.S. Food and Drug Administration warned about the entrapment danger bed rails pose all the way back in 1995.

University of Minnesota geriatrician and bioethicist Steven Miles told the New York Times that bed rails don’t improve safety for nursing home and assisted living patients. The rails do decrease the risk of falling by 10 to 15 percent, Miles said, but increase the risk of injuries by 20 percent in those falls that do occur.

Confused, groggy or medicated patients who try to climb the rails too often fall, breaking limbs or striking their heads. And some patients are trapped, their heads caught between the mattress and rail.

The Human Toll

The FDA counts more than 480 deaths and 138 injuries in hospital bed entrapment cases, with another 185 close calls. Miles said he believes those numbers represent a tiny fraction of the actual fatalities and injuries caused by bed rail entrapment.

It’s estimated that of the approximately 1.4 million people in nursing homes, assisted living facilities and rehabilitation centers, at least 140,000 are in beds with rails. That number does not include those people living at home in hospital-style beds equipped with dangerous rails.

Pursuing Justice After Tragedy

No one should have to suffer such a preventable death or sustain an avoidable injury in a nursing home. If a loved one has been taken from you in a nursing home or assisted living facility involving a bed rail and entrapment, contact a New York City wrongful death attorney for an assessment of the facts of the case. A wrongful death lawyer will advise you of your legal options and help you pursue justice.

Article provided by The Perecman Firm, P.L.L.C.
 

Chicago Tribune had an article about the Joint Commission’s new campaign to help prevent falls in health care settings and in nursing homes. Millions of Americans are injured in falls each year, and many of them are preventable with proper supervision and safety devices.  The Joint Commission’s new campaign includes brochures on prevention tips. These are things like exercise to improve balance; turning on lights when entering dark rooms; and getting help before trying to get out of a bed.

The commission’s president, Dr. Mark Chassin, points out that falls can cause life-threatening injuries and can even be fatal. And he says following these simple precautions can really help.

Restraints are not typically used in nursing homes.  However, in some situations restraints are necessary to prevent a fall incident.  The percentage of nursing home patients with restraints fell to 5% in 2007, down more than half from 1999, according to a recent report from the Agency for Healthcare Research and Quality.

Roughly 11% of all nursing home patients had restraints at the end of the last decade, according to the 2009 National Healthcare Disparities Report from AHRQ. Restraint use was at 6% in 2006.

Nursing home residents who are physically restrained for long periods are prone to pressure sores and other problems, such as chronic constipation or incontinence as well as emotional problems, according to AHRQ.