Bedrails: Restraints or Enablers?
In 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.
In Phase Two, the revised questionnaire was sent to 19 long-term care facilities. All completed and returned the questionnaire. Survey results indicated a lack of understanding among more than half of the respondents regarding the OBRA regulations that address when a bedrail is considered a restraint or enabler as well as lack of understanding with respect to documentation to support bedrail use. The majority of the respondents who stated they understood the definitions of bedrails as restraints and enablers did not present interview data to support comprehension of their correct implementation.
Survey administration. Finalized questionnaires were sent to DONs in 1% of randomly selected nursing homes in every state. Names of nursing homes were obtained from the Medicare.gov website.4 In addition, questionnaires were sent to the department responsible for nursing home surveys in all states with instructions asking that two SSs complete and return the questionnaires. Questionnaires were similar for both groups. For example, nursing home directors were asked if they had received a deficiency citation for bedrail use in the past year and if yes, to stipulate the reason for the citation. State surveyors were asked if they had issued a deficiency citation for bedrail use in the past year and, if so, the reason for the citation. Additional questions addressed the use of bedrails as restraints or enablers, documentation and policies for these uses, and personal understanding of the OBRA regulations for bedrails.
Data analysis. Data were analyzed with SPSS 11.5 software (SPSS, Inc., Chicago, Ill.). Frequency of item response was calculated for each question and t-tests were used to compare differences between groups. All states were coded and used as a variable for analysis of response.
Sample. Questionnaires were sent to 169 DONs in 50 states; 103 DONs in 45 states participated for a 61% response rate. After two mailings, five states had no participants (Idaho, Maine, Mississippi, Nevada, and Vermont). The length of service as a DON ranged from <1 year to 20 years (mean 4+4) and time working in a nursing home ranged from <1 year to >40 years (mean 15+9 years). Reasons for not returning the questionnaires included not using side rails in the facility and a general unwillingness to participate.
Sixty-five SSs from 39 states returned questionnaires; 11 state agencies (in Alabama, Arkansas, Delaware, Indiana, Kentucky, Louisiana, Minnesota, North Carolina, Ohio, Oklahoma, and Texas) chose not to participate. Of the 39 participating states, 26 returned two questionnaires and 13 returned one questionnaire. Surveyor length of service ranged from <1 year to 22 years (mean 6.5 +5 years).
Bedrail citations. Of the participating DONs, 4% reported they had received a citation for bedrail use. All of those receiving a citation said it was for using bedrails as a restraint, with half reporting inadequate documentation. Of the participating SSs, 59% reported that they had issued a deficiency citation for bedrail use in the past year. Of these, 41.5% were for bedrails used as an enabler and 37% for use as a restraint. Inadequate documentation for using bedrails as a restraint was reported in 11% of the citations, compared to 15% for enablers.
Definition and documentation of bedrails as restraint or enabler.
Directors of Nursing. In terms of bedrail use as a restraint, 54% of DONs stated they had a facility policy; in addition, 17% thought using bedrails as restraints was appropriate and 21% indicated bedrail use would be appropriate at the residents' request, 19% at the physicians' request, and 18% to assist with movement. Respondents said necessary documentation would include a multidisciplinary plan (39%), physician order (37%), fall risk assessment (34%), alternative intervention (33%), or informed consent (31%). Regarding bedrail use as an enabler, 38% of DONs responded that they had a written policy; 50.5% thought bedrail use was appropriate; 45% thought bedrails were appropriate to assist with movement; and use was considered appropriate at the resident's request (37%), physician's request (20%), and family's request (14%). Necessary documentation for bedrails as enablers would include a multidisciplinary plan (39%), physician's request (33.5%), fall risk assessment (32%), or informed consent (31%). Regarding the OBRA definitions/required documentation of bedrails as restraints, 70% of DONs thought they understood the definition and 56% understood the necessary documentation. With respect to the OBRA definition/documentation as an enabler, the results were 47% and 54%, respectively.
State surveyors. Among participating SSs, 31% thought bedrails could be appropriately used as restraints and 76% said supportive documentation was necessary. Appropriate reasons included: alternative more restrictive (41.5%), patient request (40%), or to assist with movement (34%). Necessary documentation included a multidisciplinary plan (85%), alternative intervention (83%), and a physician's order (80%). In terms of bedrails as enablers, 97% of SSs thought this appropriate and 64.5% thought supportive documentation was necessary. Appropriate reasons to use bedrails as enablers included to assist with movement (92%) and if use was at the resident's request (78.5%). Necessary documentation included multidisciplinary plan (85%), resident response implemented (65%), informed consent (61.5%), and as an alternative intervention (63%). State surveyors responded that they understood OBRA regulations regarding bedrails as restraints (81.5%) and the documentation necessary for their use (77%); 72% and 68%, respectively, understood the definition and documentation for use.
Comparison of significant differences in responses (see Table 1). Significant differences (P <0.05) between DONs and SSs were found in multiple areas. Significantly more SSs than DONs believed bedrail use was appropriate as an enabler or restraint. Significantly more SSs said bedrail use was appropriate as an enabler to assist with movement, at the resident's request, if the alternative was more restrictive, and for immobility problems. Significantly more DONs than SSs said bedrails could be used as a restraint at the physicians' or families' request to prevent movement out of bed. Differences in documentation requirements for bedrail use also were noted. Significantly more SSs felt documentation as an enabler should be included in an interdisciplinary plan of care and the resident response implemented. When bedrails are used as restraints, surveyors said a multidisciplinary plan of care, alternative intervention, a physician order, informed consent, and resident response implemented were appropriate documentation at significantly higher response levels. State surveyors also reported having a better understanding of OBRA regulations for bedrail use than DONs.
Historically, restraints have been used because elderly people, especially frail elderly, were believed to be at risk for falls and injury if they were not restrained. These assumed safety benefits have been called into question with regard to quality-of-life issues.5-7 However, bedrails also can be used as enablers, allowing residents to move from side to side, come to a sitting position, and feel secure. Until recently, only a few studies have examined bedrails as a form of restraint, their risks and benefits, psychological and demobilization effects of confinement, the documentation required to avoid deficiency citations, and outcomes of bedrail reduction in long-term care facilities.5,8-14
Despite documents such as the Health Care Financing Administration guidance to surveyors in the implementation of 42 CFR Part 482, Part 483.13(a) and CMS July, 2000 questions and answers related to use and coding of bedrails, OBRA regulations regarding bedrail use are still confusing.2 These regulations have had a mixed impact on long-term care facilities and their strategies to improve the quality of life for the elderly in the least restrictive environment possible.15,16 Clinical-legal findings show diversity in circumstances where using bedrails to prevent residents from falling or injuring themselves is construed as a duty.5 However, long-term care facilities are hesitant to use bedrails for any reason for fear of deficiency citations. One strategy has been simply to stop using any bedrails and place the mattress on the floor if a resident is thought to be at risk for falling out of bed.
Facilitating movement in bed is important to reduce the risk of pressure ulcer development. On the other hand, preventing injuries due to falling or incontinent episodes because of interference with the ability to get out of bed is also a crucial consideration. Consequently, long-term care facilities are caught between the need for and the misuse of bedrails. Results of this study showed a generalized acceptance of bedrail use as an enabler but not as a restraint by both DONs in long-term care facilities and SSs. The problem both sides are facing is the lack of congruence in appropriate reasons for bedrail use and the supportive documentation necessary. Directors of Nursing were not sure when bedrail use was appropriate, even as an enabler, and were uncertain as to how to document bedrail use to avoid citations. State surveyors indicated that a resident's request and the need to have assistance with movement were reasons bedrails could be used as enablers and that this could be documented in a multidisciplinary plan of care for the resident.
The intent of Medicare guidelines and the CMS is to standardize care for nursing home residents in the US. By requesting individual assessment and planning for restraints or alternatives to restraints through the use of an interdisciplinary team - and with input from the resident and family or the patient's legal guardian - this can be accomplished. This practice is based on both positive and negative outcomes of the decisions being discussed and documented by all parties.
Another area of confusion involves classification of the device as a restraint or enabler. The assessment is to consider, "the effect the device has on the individual - not the purpose or intent of its use. It is possible for a device to improve resident mobility and also have the effect of restraining the individual. If the side rail has the effect of restraining the resident, the facility is responsible to assess the appropriateness of the restraint."2 When choosing appropriate care for the resident, staff and caregiver safety also must be considered.
Several limitations were identified in this study. First, the term enabler as used in this study is not used in government policies or documents but is a generic term to denote alternative use of a bedrail in some way other than as a restrictive device. Also, not all states participated in this study and a larger survey of state regulators and long-term care facilities needs to be undertaken before policy decisions on appropriate documentation and use of bedrails can be achieved.
Current regulations are flexible enough that individualized interpretation by SSs and confusion between the intent of OBRA and the daily operations of nursing homes are prevalent. A balance needs to be found between use and non-use of bedrails. This can only be accomplished by fully informing residents and families - as well as the caregivers, administrators, and SSs - of the risks and benefits of bedrail use as either restraint or enabler. Education on bedrail use seems to be lacking. Further examination of the issue, including the development of interventions to improve knowledge and the development of policies and procedures leading to a consensus of appropriate use, is a crucial step to ensuring bedrails are used to their best advantage.
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