Bedrails: Restraints or Enablers?
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I n 1987, Congress passed the Omnibus Budget Reconciliation Act (OBRA) to address growing concerns about conditions in long-term care facilities. The Nursing Home Quality Reform Act (NHRA) was included in the OBRA legislation to standardize assessment, care, and treatment of the elderly in facilities receiving federal funding. Also included in the NHRA was a statement related to a resident's right of freedom and autonomy. Routine use of restraints was a common practice in 1987 and led to increased immobility and deconditioning among residents.1 Consequently, institutions were mandated to reduce the use of restraints within facilities.
The requirement to be free of physical or chemical restraints intends "for each person to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints."2 Restraints presently should be used only to ensure the physical safety of the resident or other residents.1,3 The reduction of restraints overall has been a movement toward individual-centered care to maximize resident function, safety, and autonomy. Bedrails (or siderails) were originally intended primarily for patient safety and to aid in movement in bed. Bedrails have recently come under scrutiny as a form of physical restraint. Facilities have received negative survey outcomes or citations, which may not be universally applied. Reimbursement has been affected and facilities are struggling to make changes to reverse this effect.
Currently, some healthcare facilities are opting to eliminate bedrails and some are using mattresses on the floor for sleeping. As a result, elderly individuals may develop decubitus ulcers when they are unable to reposition themselves without a bedrail. More frequent falls due to loss of perimeter definement also may occur. Although bedrail use may have advantages, facilities report concern that federal funds will be withheld if they use bedrails for any purpose. Frequently, the solution has been to refrain from using bedrails. The loss of bedrails in all instances may actually be less safe and more restrictive of movement. Such an interpretation of restraint legislation also may be counter to the intent of OBRA/NHRA legislation.
This study was designed to: 1) examine how Directors of Nursing (DONs) in long-term care institutions and Medicare state surveyors (SSs) define bedrails as enablers or restraints and what documentation they feel they need to support their use, and 2) compare definitions and documentation for bedrail use as enabler or restraint for significant differences.
Survey development. This descriptive study was designed to identify definitions of bedrails as restraints or enablers and document differences between the views of DONs at long-term care facilities and Medicare state survey teams members. A pilot project, conducted initially to develop and test the questionnaire, commenced in two phases. Phase One was questionnaire development. The preliminary questionnaire was sent to two DONs, a registered nurse employed in home care, and a physician gerontology expert. The instrument subsequently was modified to achieve face and content validity. Responses for survey questions on bedrail use and policy/documentation were derived from a review of the literature and pilot research was conducted in two western states.