Unlawful Use of Restraints

What is a Restraint?

Restraints can be divided into two categories: (a) physical restraints and (b) chemical restraints. 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:

​

• 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.

Does Florida law limit the use of restraints?

Yes. Every nursing home resident has the right to be free from physical and chemical restraints, subject to limited exceptions. 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.

Are restraints addressed in the Federal regulations?

Yes. The Federal regulations also include a prohibition on the use of restraints in nursing facilities. 42 C.F.R. 483.12(a)(2) states that a nursing home must:

Ensure that the resident is free 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).”).

What are the negative effects of physical restraints?

Research and standards of practice show that physical restraints have many negative side effects and risks that far outweigh any benefit from their use. Physical restraints may increase the risk of one or more of the following:

• 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;

• Skin breakdown around the area where the restraint was applied or skin integrity issues related to the use of the restraint (i.e., 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.

What are the negative effects 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.

If you believe your loved one was wrongfully restrained by a nursing facility, contact the experienced nursing home and assisted living facility injury attorneys at FIDJ, before it’s too late.