Unlawful Use of Restraints in Florida Nursing Homes, Assisted Living Facilities, Group Homes, & Adult Day Care Centers

Understanding the Difference between Physical & Chemical Restraints

Restraints in nursing homes, assisted living facilities, group homes, and adult day care centers typically fall into two categories: physical restraints and chemical restraints. 

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A physical restraint is generally defined as any manual method, physical or mechanical device, equipment, or material that (a) is attached or adjacent to the resident’s body; (b) cannot be removed easily by the resident; and (c) restricts the resident’s freedom of movement or normal access to his/her body. “Removes easily” means that the manual method, physical or mechanical device, equipment, or material, can be removed intentionally by the resident in the same manner as it was applied by the staff. Some examples of physical restraints include:

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• Using a bed rail, if the bed rail prevents the resident from getting out of bed;

• Using a lap belt or seat belt on a wheelchair that the resident cannot intentionally release on his or her own;

• Placing a chair or bed close enough to a wall that the resident is prevented from rising out of the chair or voluntarily getting out of bed;

• Placing a resident on a concave mattress so that the resident cannot independently get out of bed;

• Tucking in a sheet tightly so that the resident cannot get out of bed, or fastening fabric or clothing so that a resident’s freedom of movement is restricted; 

• Placing a resident in a chair, such as a beanbag or recliner, that prevents a resident from rising independently; 

• Using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts, that the resident cannot remove and prevents the resident from rising;

• Applying leg or arm restraints, hand mitts, soft ties or vests that the resident cannot remove;

• Holding down a resident in response to a behavioral symptom or during the provision of care if the resident is resistive or refusing the care;

• Placing a resident in an enclosed framed wheeled walker, in which the resident cannot open the front gate or if the device has been altered to prevent the resident from exiting the device; and

• Using a position change alarm to monitor resident movement, and the resident is afraid to move to avoid setting off the alarm.

A chemical restraint is generally defined as any drug that is used for discipline or staff convenience and is not required to treat medical symptoms. “Convenience” is defined as the result of any action that has the effect of altering a resident’s behavior such that the resident requires a lesser amount of effort or care, and is not in the resident’s best interest. A medication properly prescribed by a resident's physician that also caused drowsiness would generally not be considered a chemical restraint.

When any medication restricts the resident’s movement or cognition, sedates or subdues the resident, and is not an accepted standard of practice for a resident’s medical or psychiatric condition, the medication may be a chemical restraint. Even if use of the medication follows accepted standards of practice, it may be a chemical restraint if there was a less restrictive alternative treatment that could have been given that would meet the resident’s needs and preferences or if the medical symptom justifying its use has subsided. An example of a chemical restraint might include giving a resident Benadryl solely to make the resident drowsy so he or she sleeps through the day and/or night, requiring a lesser amount of care or staff effort.

Florida Protections Against the Improper Use of Restraints

Every nursing home, assisted living facility, group home, and adult day care center resident has the right to be free from physical and chemical restraints, subject to limited exceptions.

• Nursing Homes:  Florida Statute 400.022(1)(o) states that all nursing home residents have the right:

[T]o be free from mental and physical abuse, corporal punishment, extended involuntary seclusion, and from physical and chemical restraints, except those restraints authorized in writing by a physician for a specified and limited period of time or as are necessitated by an emergency. In case of an emergency, restraint may be applied only by a qualified licensed nurse who shall set forth in writing the circumstances requiring the use of restraint, and, in the case of use of a chemical restraint, a physician shall be consulted immediately thereafter. Restraints may not be used in lieu of staff supervision or merely for staff convenience, for punishment, or for reasons other than resident protection or safety.

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• Assisted Living Facilities: Florida Statute 429.41(1)(j) states that all assisted living facility residents have the to to be free from "physical or chemical restraints" and that the "use of Posey restrains is prohibited."

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Other physical restraints may be used in accordance with agency rules when ordered by the resident’s physician and consented to by the resident or, if applicable, the resident’s representative or designee or the resident’s surrogate, guardian, or attorney in fact. Such rules must specify requirements for care planning, staff monitoring, and periodic review by a physician. The use of chemical restraints is limited to prescribed dosages of medications authorized by the resident’s physician and must be consistent with the resident’s diagnosis. Residents who are receiving medications that can serve as chemical restraints must be evaluated by their physician at least annually to assess: 1. The continued need for the medication. 2. The level of the medication in the resident’s blood. 3. The need for adjustments in the prescription. ​

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• Group Homes: Florida Statute 393.13(3)(g) states that individuals with developmental disabilities "shall have a right to be free from harm, including unnecessary physical, chemical, or mechanical restraint, isolation, excessive medication, abuse, or neglect." Florida Statute 393.13(4)(h) further states tjat group home residents shall have the right:

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[T]o be free from the unnecessary use of restraint or seclusion. Restraints shall be employed only in emergencies or to protect the client or others from imminent injury. Restraints may not be employed as punishment, for the convenience of staff, or as a substitute for a support plan. Restraints shall impose the least possible restrictions consistent with their purpose and shall be removed when the emergency ends. Restraints shall not cause physical injury to the client and shall be designed to allow the greatest possible comfort.

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• Adult Day Care Centers: Florida Administrative Code 59A-16.103(3)(g) states that adult day care center participants must be "free from chemical and phsyical restraints" further noting that "medications shall not be used for punishment, convenience of Staff, or in quantities that interfere with a Participant's  rehabilitation or Activities of Daily Living."

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Federal Protections Against the Improper Use of Restraints

Federal regulations offer additional safeguards against the misuse of restraints in long-term care settings. 42 C.F.R. 483.12(a)(2) states that residents have the right to be: 

[F]ree from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

See also 42 C.F.R. 483.10(e) (“The resident has a right to be treated with respect and dignity, including (1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with § 483.12(a)(2).”).

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These federal protections apply not just to nursing homes but also help set the standard of care expected in all federally regulated long-term care environments.

The Dangers of Physical Restraints

Modern research and clinical standards overwhelmingly warn against the use of physical restraints. Far from being protective, restraints often create additional harm, both physically and psychologically. Documented risks of physical restraints include:

• Decline in physical functioning, including an increased dependence with activities of daily living (e.g., ability to walk), impaired muscle strength and balance, decline in range of motion, and risk for development of contractures;

• Respiratory complications;

• Increased risk of skin breakdown around the area where the restraint was applied or skin integrity issues related to the use of the restraint (e.g., pressure ulcers/injuries);

• Urinary/bowel incontinence or constipation;

• Injury from attempts to free him/herself from the restraint; and

• Accidents such as falls, strangulation, or entrapment.

Residents may also experience adverse psychosocial impacts related to the use of physical restraints, including, but not limited to, agitation, aggression, anxiety, development of delirium, social withdrawal, depression, reduced social contact due to the loss of autonomy; feelings of shame; loss of dignity, self‐respect, and identity; dehumanization; panic, feeling threatened or fearful; and feelings of imprisonment or restriction of freedom of movement.

The Dangers of Chemical Restraints

A medication that is used for discipline or convenience and is not required to treat medical symptoms may cause the resident to be subdued, sedated, or withdrawn; asleep during hours that he/she would not ordinarily be asleep; or limited in his/her functional capacity. Additional effects resulting from sedating or subduing a resident may include, but are not limited to, the following:

• Loss of autonomy, dignity, self-respect, and orientation;

• Confusion, cognitive decline, withdrawal, depression;

• Decreased activity levels, including social activities;

• Decline in skin integrity;

• Decline in continence level;

• Decline in physical functioning, including an increased dependence with activities of daily living (e.g., ability to walk), impaired muscle strength and balance, decline in range of motion, risk for development of contractures, and increased risk of falls; and

• Weight loss if missing meals.

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Contact FIDJ for a Free Case Review

If you believe your loved one was wrongfully restrained and injured by a nursing home, assisted living facility, group home, or adult day care center, contact the experienced attorneys at FIDJ for a FREE case review.