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Resident Behavior and Facility Practices

 
Description of Federal Requirements
Comparison of State Requirements
Table Comparing States
Complete Transcript of State Requirements on Resident Behavior and Facility Practices (PDF)

Federal Regulations & Related F-tags for 483.13 Applicable Federal Regulation
(a) Restraints | F222
(b) Abuse | F223
(6) Staff treatment of residents | F244
 
483.13 Resident Behavior and Facility Practices

Description of Federal Requirements    (TOP)    (NEXT)

The federal regulation 483.13 concerns prohibition and reporting of various kinds of abuse and mistreatment of nursing home residents. It contains three sections relating to: (a) physical and chemical restraints, (b) abuse of residents, and (c) staff policies to prohibit various forms of resident mistreatment. The regulation on restraints states that residents must be free of physical and chemical restraints imposed for disciplinary or convenience purposes and that are unnecessary to treat medical symptoms. The regulation on abuse simply states that residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

The final section requires facilities to develop written policies to prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Its subparts require that the facility not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion, not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law, who have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and that it report to the State nurse aide registry or licensing authorities any knowledge it has about the criminal status of an employee that would indicate the employee is unfit to serve as a nurse aide or a staff member of a nursing home. The policies developed by the facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials as required by State law. The facility must ensure that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress, and the results of the facility's investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

The prohibitions of abuse and the requirements for the facility to investigate and report allegations of abuse are complemented by a section in the Resident Rights Regulation (483.5) (b) (7) (iv) where, as part of the notice of rights and services, the facility must furnish a written description of legal rights which includes a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, misappropriation of resident property in the facility, and non-compliance with the advance directives requirements. Another Section, (c), of Resident Rights deals with the correct protection of resident funds; by extrapolation the failure to follow these rules could constitute misappropriation of resident funds. We found no other direct reference to physical restraints in the Federal regulations, although the assessment instrument mandated under the regulation on Resident Assessment (483.20) contains items on the use of physical restraints and bedrails, and the rate of physical restraint use is one of the quality measures that is reported for each nursing home. The regulation on Quality of Care deals in detail with unnecessary drugs. This provision includes definitions of unnecessary drugs (i.e. excessive dose, excessive duration, inadequate monitoring, inadequate clinical indications, and adverse consequences) (483.25 (l). It especially discusses the use of antipsychotic drugs, requiring that they not be used unless they are necessary to treat a specific condition diagnosed and documented in the clinical record. Similar to restraints, the resident's medications are reported in a specific section of the Resident Assessment (483.20) and several quality indicators are in use to characterize facilities in terms of their use of medications (e.g. use of large numbers of prescription drugs, use of antipsychotic drugs, use of psychoactive drugs in general). Under the Administration Regulation (483.75) (d) (6) on Required Training of Nurse's Aides, before allowing an individual to serve as a nurse aide, a facility must seek information from every State registry established under sections 1819(e)(2)(A) or 1919(e)(2)(A) of the Act that the facility believes will include information on the individual. Although this provision is found in a section on competence of nursing aides, the stipulation on registries is designed to rule out employees with a history that might suggest abuse or mistreatment of residents or reveal criminal records.

Comparison of State Requirements    (TOP)    (NEXT)

NOTE:  The examples below may not list all States with similar language; always check your state for specifics

We found language in all 50 States plus the District of Columbia that go beyond Federal requirements on resident behavior and facility practices on restraints, abuse and staff treatment of residents. Some States treat physical and chemical restraints together, with language limiting the conditions of use for both. Most States largely treat the two kinds of restraint separately, especially because chemical restraints introduce the whole area of appropriate use of prescription drugs, and the subtle intentionality of using a medication to control behavior. [NHPlusComments: The efforts to minimize or even eliminate physical restraints in nursing homes and ensure that medications not be used inappropriately as an alternative form of restraint and behavior control date at least to the 1980s, and are supported by a strong data base on the physical as well as psychological and social problems of physical restraints. This section of the Federal rules is clearly identified with resident autonomy and dignity, and additional State regulation in this area has a high likelihood of being supportive rather than detrimental to resident autonomy and well-being.] [NHPlusComments:  The efforts to minimize or even eliminate physical restraints in nursing homes and ensure that medications not be used inappropriately as an alternative form of restraint and behavior control date at least to the 1980s, and are supported by a strong data base on the physical as well as psychological and social problems of physical restraints.  This section of the Federal rules is clearly identified with resident autonomy and dignity, and additional State regulation in this area has a high likelihood of being supportive rather than detrimental to resident autonomy and well-being.]

Some States treat physical and chemical restraints together, with language limiting the conditions of use for both.  Most States largely treat the two kinds of restraint separately, especially because chemical restraints introduce the whole area of appropriate use of prescription drugs, and the subtle intentionality of using a medication to control behavior.

Physical Restraints    (TOP)    (NEXT)

The added State provisions that we identified on physical restraints range from brief to elaborate. Many States provide definitions to clarify what will be included, in which case they make clear by phrases such as "not limited to," that any creative effort to restrict a resident in ways not delineated will be considered a restraint. State definitions may include certain types of Dutch doors, chairs from which rising is difficult, beds that are made up too tightly or anything that reduces mobility and free motion. Some States prohibit certain kinds of restraints altogether, such as leather cuffs or locking devices. For example, in Colorado, a physical restraint is a device or application of force that is designed to modify behavior detrimental to the resident, others or the facility. Physical restraints include without limitation, straight jackets, hard leather cuffs, or locking devices. Bed linens may not be used as a restraint. In Georgia, restraints include, but not limited to, any contrivance, situation, safety device, or medication that has the purposeful or incidental effect of restricting a resident's mobility within or outside of the facility grounds. In New Jersey, physical restraint includes, but is not limited to, any article, device, or garment which interferes with the free movement of the resident and which the resident is unable to remove easily. New York refers to physical restraints as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. In Nevada, physical restraints include any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. In New Mexico, physical restraint includes, but is not limited to, any article, device, or garment which interferes with the free movement of the resident and which the resident is unable to remove easily. In Wisconsin, physical restraint means any manual method, article, device or garment used pri¬marily to modify resident behavior by interfering with the free movement of the resident or normal functioning of a portion of the body, and which the resident is unable to remove easily, or confinement in a locked room, but does not include a mechanical support.

Many States make somewhat detailed distinctions between supportive devices that enhance functioning, on the one hand, and restraints, on the other, and provide detail about the use of both. Ohio describes restrictions that will not count as a restraint, including locked dementia care units and Dutch doors, if they are used in the manner specified in the rules. Jackets, sheets, cuffs, belts, or mitts made with unprotected elements of materials such as heavy canvas, leather, or metal shall not be used as restraints in Ohio. In Oregon, all physical restraints must allow for quick release, locked restraints may not be used, and the resident must not be restrained by being tied to a fixed object. Some more detailed definitions follow:

► In Minnesota, physical restraints mean any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints include, but are not limited to, leg restraints, arm restraints, hand mitts, soft ties or vests, and wheelchair safety bars. Physical restraints also include practices which meet the definition of a restraint, such as tucking in a sheet so tightly that a resident confined to bed cannot move; bed rails; chairs that prevent rising; or placing a resident in a wheelchair so close to a wall that the wall prevents the resident from rising. Bed rails are considered a restraint if they restrict freedom of movement. If the bed rail is used solely to assist the resident in turning or to help the resident get out of bed, then the bed rail is not used as a restraint. Wrist bands or devices on clothing that trigger electronic alarms to warn staff that a resident is leaving a room or area do not, in and of themselves, restrict freedom of movement and should not be considered restraints.

► In Iowa, where a classification system is used, physical restraints are defined as the following: Type I-the equipment used to promote the safety of the individual but is not applied directly to their person. Examples: divided doors and totally enclosed cribs. Type II-the application of a device to the body to promote safety of the individual. Examples: vest devices, soft-tie devices, hand socks, geriatric chairs. Type III-the application of a device to any part of the body which will inhibit the movement of that part of the body only. Examples: wrist, ankle or leg restraints and waist straps. . . . Locked restraints or leather restraints shall not be permitted except in life-threatening situations. Straight jackets and secluding residents behind locked doors shall not be employed. [NHRegsPlus Comment: Iowa's rules for restraint use are extremely detailed and refer back to the types of restraint.]

Commonly, States require some variations of the following in their specific regulations: that physical restraints are prescribed by a physician, that the facility has written policies regarding restraint use, that restraints be prescribed for limited time periods, that their use be reviewed at frequent intervals, and that less restrictive approaches be identified. Standing orders or p.r.n (that is "take as needed") orders for physical restraints are sometimes prohibited. In Alaska, for example, a resident's medical records must contain evidence of consultation with appropriate health professionals, such as occupational or physical therapists, in the use of less restrictive supportive devices before using physical restraints. The record must also contain evidence of an interdisciplinary team's identification of less restrictive approaches to be used before or in conjunction with the use of psychoactive drugs. In Colorado, the facility shall establish written policies and procedures governing the use of physical and chemical restraints and shall assure that they are followed by all staff members. Physical and chemical restraints shall only be used upon the order of a physician and only when necessary to prevent injury to the resident or others, based on a physical, functional, emotional and medication assessment. In Iowa, if a resident's behavior is such that it may result in injury to the resident or others and any form of physical restraint is utilized, it should be in conjunction with a treatment procedures(s) designed to modify the behavioral problems for which the resident is restrained, or as a last resort, after failure of attempted therapy. In Michigan, restraints are authorized in writing by the attending physician for a specified and limited time or as are necessitated by an emergency to protect the patient or resident from injury to self or others, in which case the restraint may only be applied by a qualified professional who shall set forth in writing the circumstances requiring the use of restraints and who shall promptly report the action to the attending physician.

► In Ohio, if a physical restraint is ordered; the nursing home shall select the restraint appropriate for the physical build and characteristics of the resident and shall follow the manufacturer's instructions in applying the restraint. The nursing home shall ensure that correct application of the restraint is supervised by a nurse and that the restrained resident is monitored every thirty minutes. The visual monitoring of the restrained resident may be delegated as permitted under state law.

► In Maryland, physical restraints may be used only:

(1) As an integral part of an individual medical treatment plan;

(2) If absolutely necessary to protect the resident or others from injury;

(3) If prescribed by a physician or administered by another health care professional practicing within the scope of their license; and

(4) If less restrictive alternatives were considered and appropriately ruled out by the physician.

States also are often very detailed in their requirements for the way restraints are used, monitored, and released at specific intervals, with the intervals varying by type of restraint and by State. Special requirements may include assuring that the resident's skin condition is intact, allowing for frequent exercise and toileting, and ensuring that the person who is physically restrained can be mobile in an emergency. Rules may be specific also as to the qualifications of personnel who may monitor the restraint use and the kind of delegation permissible. For example, in Colorado, residents in physical restraints shall be monitored at least every 15 minutes to assure that the resident is properly positioned, blood circulation is not restricted, and other resident needs are met; and at least every two hours during waking hours, residents shall have the physical restraint removed and shall have the opportunity to: drink fluids, be toileted, and be exercised, moved, or repositioned, which activity shall be documented in the health record. In Connecticut, the physician shall be required to renew the order for such restraint and to indicate the reason for such restraint at least every ten days. Licensed nurses may use physical restraints without a physician's order to protect the patient, or others in the institution, if such nurse or nurses deem that this action is necessary, but the physician is notified as soon as the patient is safely under control and the physician shall visit the institution to take appropriate action in regard to the nurse's decision within eight hours of the notification. In Oregon, residents who are physically restrained must have the restraints released at least every two hours for a minimum of ten minutes and be repositioned, exercised or provided range of motion during this period. Toileting and incontinence care shall be provided when necessary.

States often have established requirements for the use of physical restraints that are so time-consuming and onerous for staff that no time-saving convenience could be obtained for staff in their use. The extracts below provide examples the level of detail that some States have. Note that Illinois specifies requirements when restraints are used for a resident who uses sign language or gestures as primary communication.

► In Colorado, whenever restraints are used, a call signal switch or similar device within reach or other appropriate method of communication shall be provided to the resident. In an emergency in which there is documented danger of injury to self or others, a registered nurse or licensed practical nurse may order a physical restraint. The nature of the emergency shall be documented in the health record and a physician's order for the restraint shall be obtained as soon as practicable but in no event later than 24 hours after the restraint is first used. Residents in physical restraints shall be monitored at least every 15 minutes to assure that the resident is properly positioned, blood circulation is not restricted, and other resident needs are met. At least every two hours during waking hours, residents shall have the physical restraint removed and shall have the opportunity to: drink fluids, be toileted, and be exercised, moved, or repositioned, which activity shall be documented in the health record.

► In Georgia, except in an emergency situation described in subsection (c) of this rule, below, restraints, restrictions, or isolation must be authorized as follows:

1. Prior to authorizing restraints, restrictions, or isolation, the attending physician shall make a personal examination and individualized determination that such restraint, restriction, or isolation is necessary to protect the resident or other persons from immediate injury; and

2. The physician shall specify the length of time for which such restraint, restriction, or isolation is authorized. Such authorization may not exceed 65 days for intermediate care home residents or 35 days for skilled nursing home residents, but in no event shall such restraint, restriction, or isolation be used beyond the period of actual need to protect the resident or other persons from immediate injury. Any period beyond that specified shall be regarded as a new period and all requirements for the use of such restraints, restriction or isolation must be met.

(c) In an emergency situation severely threatening the health or safety of the resident or others, restraints, restrictions, or isolation may be authorized only by the person in charge. In an emergency situation, restraints, restrictions or isolation may be used only for 12 hours from the time of onset of the emergency situation. Beyond the 12-hour period, restraints, restrictions, or isolation may not be used unless it is in accordance with subsection (b) of this rule.

(d) The resident and guardian or persons designated by the resident, if any, shall be immediately informed of the need for such restraints, restrictions or isolation, the reasons for such use, and the time specified for such use.

(e) A restrained or isolated resident shall be monitored by staff at least every hour. A restrained or isolated resident must be released and exercised every two hours except during normal sleeping hours. Such activities shall be documented in the resident's record.

(f) A resident who is restrained, restricted or isolated pursuant to this section shall retain all other rights and responsibilities provided by these rules and regulations.

► In Illinois, whenever a period of use of a physical restraint is initiated, the resident shall be advised of his or her right to have a person or organization of his or her choosing, including the Guardianship and Advocacy Commission, notified of the use of the physical restraint. A period of use is initiated when a physical restraint is applied to a resident for the first time under a new or renewed informed consent for the use of physical restraints. A recipient who is under guardianship may request that a person or organization of his or her choosing be notified of the physical restraint, whether or not the guardian approves the notice. If the resident so chooses, the facility shall make the notification within 24 hours, including any information about the period of time that the physical restraint is to be used. Whenever the Guardianship and Advocacy Commission is notified that a resident has been restrained, it shall contact the resident to determine the circumstances of the restraint and whether further action is warranted. (Section 2-106(e) of the Act) If the resident requests that the Guardianship and Advocacy Commission be contacted, the facility shall provide the following information in writing to the Guardianship and Advocacy Commission:

1) the reason the physical restraint was needed;

2) the type of physical restraint that was used;

3) the interventions utilized or considered prior to physical restraint and the impact of these interventions;

4) the length of time the physical restraint was to be applied; and

5) the name and title of the facility person who should be contacted for further information

g) Whenever a physical restraint is used on a resident whose primary mode of communication is sign language, the resident shall be permitted to have his or her hands free from restraint for brief periods each hour, except when this freedom may result in physical harm to the resident or others.

► In New York, when physical restraints are used: they are time limited. They are used for specified periods of time, properly applied allowing for some body movement and not impairing circulation;(ii) they are monitored closely as specified in paragraph (5) of this subdivision; and iii) all plans for restraints are reviewed at a frequency determined by the resident's condition or more frequently if requested by the resident or designated representative. The clinical record shall include documentation of periodic reevaluation of the need for the restraint and efforts made to substitute other measures.

(4) Policies and procedures regarding the ordering and use of physical restraints and the recording, reporting, monitoring and review and modification thereof are:

(i) incorporated into the in-service education programs of the facility, with changes made in such programs when policies and procedures are modified; and (ii) made known to all medical, nursing and other appropriate resident care personnel in advance of implementation.

(5) When physical restraints are used the resident is:

(i) released as frequently as necessary to meet resident care needs, but at least every two hours except when asleep in bed, then released as indicated by the type of restraint and by the residents' condition;

(ii) provided with changes of position, ambulation or exercise at the time of release; and

(iii) observed at least as frequently as at the time of dressing and undressing for any evidence of adverse effects, including but not limited to circulatory problems or skin abrasions.

► In Ohio, if a physical restraint is ordered; the nursing home shall select the restraint appropriate for the physical build and characteristics of the resident and shall follow the manufacturer's instructions in applying the restraint. The nursing home shall ensure that correct application of the restraint is supervised by a nurse and that the restrained resident is monitored every thirty minutes. The visual monitoring of the restrained resident may be delegated as permitted under state law.

► In North Carolina, within a facility when restrictive interventions are used, the policy and procedures shall be in accordance with the following provisions:

(1)  the requirement that positive and less restrictive alternatives are considered and attempted whenever possible prior to the use of more restrictive interventions;

(2)  consideration is given to the client's physical and psychological well-being before, during and after utilization of a restrictive intervention, including:

(A)  review of the client's health history or the client's comprehensive health assessment conducted upon admission to a facility. The health history or comprehensive health assessment shall include the identification of pre-existing medical conditions or any disabilities and limitations that would place the client at greater risk during the use of restrictive interventions;

(B)  continuous assessment and monitoring of the physical and psychological well- being of the client and the safe use of restraint throughout the duration of the restrictive intervention by staff who are physically present and trained in the use of emergency safety interventions;

(C)  continuous monitoring by an individual trained in the use of cardiopulmonary resuscitation of the client's physical and psychological well-being during the use of manual restraint; and

(D)  continued monitoring by an individual trained in the use of cardiopulmonary resuscitation of the client's physical and psychological well-being for a minimum of 30 minutes subsequent to the termination of a restrictive intervention;

(3)  the process for identifying, training, assessing competence of facility employees who may authorize and implement restrictive interventions;

(4)  the duties and responsibilities of responsible professionals regarding the use of restrictive interventions;

(5)  the person responsible for documentation when restrictive interventions are used;

(6)  the person responsible for the notification of others when restrictive interventions are used; and

(7)  the person responsible for checking the client's physical and psychological well-being and assessing the possible consequences of the use of a restrictive intervention and, in such cases there shall be procedures regarding:

(A)  documentation if a client has a physical disability or has had surgery that would make affected nerves and bones sensitive to injury; and

(B)  the identification and documentation of alternative emergency procedures, if needed;

Some States have specifically required informed consent of the resident and/or family and guardians, and have elaborated the risks associated with physical restraints. Oregon specifically refers to the right of the resident or resident's agent to make a decision about whether to risk falls. In Florida, the use of physical restraints is limited to half-bed rails as prescribed and documented by the resident's physician with the consent of the resident or, if applicable, the resident's representative or designee or the resident's surrogate, guardian, or attorney in fact. Illinois, Minnesota and Iowa also require informed consents. Iowa also contains separate extensive provisions for written consent of family and guardians for restraints or restrictive treatment, including the use of aversive stimuli in the case of residents with mental retardation. In Ohio, the facility shall discuss with the resident or authorized representative, and any other individual designated or authorized by the resident, the risks and benefits of the restraint; and obtain written consent from the resident or the resident's authorized representative. In Rhode Island, if after a trial of less restrictive measures, the facility decides that a physical restraint would enable and promote greater functional independence, then the use of the restraining device must first be explained to the resident, family member, or legal representative, and if the resident, family member or legal representative agrees to this treatment alternative, then the restraining device may be used for the specific periods for which the restraint has been determined to serve the purposes allowed in the rules. In North Carolina, the consent must be renewed every six months.

 Often the language of consent is combined with requirements for multidisciplinary planning or specialized services to find an alternative to physical restraints.

► In Alaska, a resident's medical records must contain evidence of consultation with appropriate health professionals, such as occupational or physical therapists, in the use of less restrictive supportive devices before using physical restraints. The record must also contain evidence of an interdisciplinary team's identification of less restrictive approaches to be used before or in conjunction with the use of psychoactive drugs.

(c) If, after a trial period of less restrictive measures, a nursing facility decides that a physical restraint or psychoactive drug would enable and promote greater functional or social independence, the nursing facility must explain the use of the restraint or psychoactive drug to the resident, before its use. If the resident has a legal representative, the explanation must also be given to the resident's legal representative, before its use. The explanation must include a description of the risks and benefits of the use of the restraint or drug.

(d) Approval of the use of a restraint or psychoactive drug by a resident, or legal representative must precede its use, except in the case of a medical emergency in which there is a risk of harm to the resident or others.

► In New York, physical restraints are used only in unusual circumstances and only after all reasonable less restrictive alternatives have been considered and rejected for reasons related to the resident's well-being which shall be documented showing evidence of consultation with appropriate professionals such as social workers and physical therapists. Less restrictive measures that would not clearly jeopardize the resident's safety shall not be rejected before a trial to demonstrate whether a more restrictive restraint would promote greater functional independence.

► In North Carolina (where consents and notifications are tied to a habilitation pan):

(1)  the requirement that a consent or approval shall be considered valid for no more than six months and that the decision to continue the specific intervention shall be based on clear and recent behavioral evidence that the intervention is having a positive impact and continues to be needed;

(2)  prior to the initiation or continued use of any planned intervention, the following written notifications, consents and approvals shall be obtained and documented in the client record:

(A)  approval of the plan by the responsible professional and the treatment and habilitation team, if applicable, shall be based on an assessment of the client and a review of the documentation required by Subparagraph (e)(9) and (e)(14) of this Rule if applicable;

(B)  consent of the client or legally responsible person, after participation in treatment planning and after the specific intervention and the reason for it have been explained in accordance with 10A NCAC 27D .0201;
27D .0201;

(C)  notification of an advocate/client rights representative that the specific intervention has been planned for the client and the rationale for utilization of the intervention; and

(D)  physician approval, after an initial medical examination, when the plan includes a specific intervention with reasonably foreseeable physical consequences. In such cases, periodic planned monitoring by a physician shall be incorporated into the plan.

(3)  within 30 days of initiation of the use of a planned intervention, the Intervention Advisory Committee established in accordance with Rule .0106 of this Section, by majority vote, may recommend approval or disapproval of the plan or may abstain from making a recommendation;

(4)  within any time during the use of a planned intervention, if requested, the Intervention Advisory Committee shall be given the opportunity to review the treatment/habilitation plan;

(5)  if any of the persons or committees specified in Subparagraphs (h)(2) or (h)(3) of this Rule do not approve the initial use or continued use of a planned intervention, the intervention shall not be initiated or continued. Appeals regarding the resolution of any disagreement over the use of the planned intervention shall be handled in accordance with governing body policy; and

(6)  documentation in the client record regarding the use of a planned intervention shall indicate:

(A)  description and frequency of debriefing with the client, legally responsible person, if applicable, and staff if determined to be clinically necessary. Debriefing shall be conducted as to the level of cognitive functioning of the client;

(B)  bi-monthly evaluation of the planned by the responsible professional who approved the planned intervention; and

(C)  review, at least monthly, by the treatment/habilitation team that approved the planned intervention.

► In Oregon, as part of freedom of choice, when restraints are considered in the interdisciplinary care planning conference to reduce the risk of injury related to falls, the resident or his/her legal guardian or person acting under the resident's power of attorney for health care must be informed of the potential risks of falling and the risks associated with restraints;

(b) Physician Orders Required. Except as provided in subsection (3)(c) of this rule, physical and chemical restraints may be applied only when a physician orders restraints. An order for restraints must clearly identify the reason for the restraints and the duration and circumstances under which they are to be applied;

(c) Emergencies. In an emergency situation, a registered nurse may use physical restraints without physician orders if necessary to prevent injury to the resident or to other residents and when alternative measures do not work. If restraints are used in an emergency situation, the registered nurse shall document in the resident's clinical record the use of restraints and what alternative measures did not work. A licensed nurse shall contact the physician for restraint orders within 12 hours of application;

(d) Re-evaluation. Whenever restraints are used, circumstances requiring the restraints and the need must be continually re-evaluated and documented in the clinical record.

► In Washington, when chemical or physical restraints are used the nursing home must ensure that:
(a) The use of the restraint is related to a specific medical need or problem identified through a multidisciplinary assessment;
(b) The informed consent process is followed as described under WAC 388-97-060; and
(c) The resident's plan of care provides approaches to reduce or eliminate the use of the restraint, where possible.

Many States specify the kinds of policies that need to be in place facility-wide to limit the use of restraints, find alternatives, and prepare staff both to avoid restraints and to use them properly. Typically staff education is included in these policies Delaware, for example, the facility must maintain the resident's environment and care through appropriate nurse aide behavior so as to minimize the need for physical and chemical restraints, and restraints must be applied by nurses and nurse's aides who have been trained in the procedures. In Iowa, which also has detailed procedures and policies related to each type of restraint, the facility shall provide orientation and ongoing education programs in the proper use of restraints. Examples of detailed approaches to facility policies are found in Illinois, New Jersey and New York.

► In Illinois, the facility shall have written policies controlling the use of physical restraints including, but not limited to, leg restraints, arm restraints, hand mitts, soft ties or vests, wheelchair safety bars and lap trays, and all facility practices that meet the definition of a restraint, such as tucking in a sheet so tightly that a bed-bound resident cannot move; bed rails used to keep a resident from getting out of bed; chairs that prevent rising; or placing a resident who uses a wheelchair so close to a wall that the wall prevents the resident from rising. Adaptive equipment is not considered a physical restraint. Wrist bands or devices on clothing that trigger electronic alarms to warn staff that a resident is leaving a room do not, in and of themselves, restrict freedom of movement and should not be considered as physical restraints. The policies shall be followed in the operation of the facility and shall comply with the Act and this Part. These policies shall be developed by the medical advisory committee or the advisory physician with participation by nursing and administrative personnel.

b) No physical restraints with locks shall be used.

c) Physical restraints shall not be used on a resident for the purpose of discipline or convenience.

d) The use of chemical restraints is prohibited.

(Source: Amended at 20 Ill. Reg. 12160, effective September 10, 1996) Section 300.682 Nonemergency Use of Physical Restraints

a) Physical restraints shall only be used when required to treat the resident's medical symptoms or as a therapeutic intervention, as ordered by a physician, and based on:

1) the assessment of the resident's capabilities and an evaluation and trial of less restrictive alternatives that could prove effective;

2) the assessment of a specific physical condition or medical treatment that requires the use of physical restraints, and how the use of physical restraints will assist the resident in reaching his or her highest practicable physical, mental or psychosocial well being;

3) consultation with appropriate health professionals, such as rehabilitation nurses and occupational or physical therapists, which indicates that the use of less restrictive measures or therapeutic interventions has proven ineffective; and 4) demonstration by the care planning process that using a physical restraint as a therapeutic intervention will promote the care and services necessary for the resident to attain or maintain the highest practicable physical, mental or psychosocial well being. (Section 2-106(c) of the Act)

b) A physical restraint may be used only with the informed consent of the resident, the resident's guardian, or other authorized representative. (Section 2-106(c) of the Act) Informed consent includes information about potential negative outcomes of physical restraint use, including incontinence, decreased range of motion, decreased ability to ambulate, symptoms of withdrawal or depression, or reduced social contact.

c) The informed consent may authorize the use of a physical restraint only for a specified period of time. The effectiveness of the physical restraint in treating medical symptoms or as a therapeutic intervention and any negative impact on the resident shall be assessed by the facility throughout the period of time the physical restraint is used.

d) After 50 percent of the period of physical restraint use authorized by the informed consent has expired, but not less than 5 days before it has expired, information about the actual effectiveness of the physical restraint in treating the resident's medical symptoms or as a therapeutic intervention and about any actual negative impact on the resident shall be given to the resident, resident's guardian, or other authorized representative before the facility secures an informed consent for an additional period of time. Information about the effectiveness of the physical restraint program and about any negative impact on the resident shall be provided in writing.

e) A physical restraint may be applied only by staff trained in the application of the particular type of restraint. (Section 2-106(d) Act)

► In New Jersey, a facility must revise as needed, and ensure implementation of written policies and procedures for the use of restraints and assure that the facility continuously attempts to eliminate the need for restraints. Guidance for such policies and procedures is provided in Appendix D of this chapter. Policies shall include the collection of the following data:

1. All emergency restraint applications;

2. Indicators for the frequency of the use of restraints in the facility;

3. Evaluation of all cases in which there is:

i. A failure to obtain or receive a physician's or advanced practice nurse's order;

ii. A negative clinical outcome; and

4. Indicators of the frequency of the use of psychopharmacological agents.

(d) All nursing and professional staff of the facility shall receive orientation and annual training in the use of restraints, including at least:

1. Emergency and non-emergency procedures;

2. Practice in the application of restraints and alternative methods of intervention; and

3. Interventions by licensed and non-licensed nursing personnel.

(D)  physician approval, after an initial medical examination, when the plan includes a specific intervention with reasonably foreseeable physical consequences. In such cases, periodic planned monitoring by a physician shall be incorporated into the plan.

(3)  within 30 days of initiation of the use of a planned intervention, the Intervention Advisory Committee established in accordance with Rule .0106 of this Section, by majority vote, may recommend approval or disapproval of the plan or may abstain from making a recommendation;

(4)  within any time during the use of a planned intervention, if requested, the Intervention Advisory Committee shall be given the opportunity to review the treatment/habilitation plan;

(5)  if any of the persons or committees specified in Subparagraphs (h)(2) or (h)(3) of this Rule do not approve the initial use or continued use of a planned intervention, the intervention shall not be initiated or continued. Appeals regarding the resolution of any disagreement over the use of the planned intervention shall be handled in accordance with governing body policy; and

(6)  documentation in the client record regarding the use of a planned intervention shall indicate:

(A)  description and frequency of debriefing with the client, legally responsible person, if applicable, and staff if determined to be clinically necessary. Debriefing shall be conducted as to the level of cognitive functioning of the client;

(B)  bi-monthly evaluation of the planned by the responsible professional who approved the planned intervention; and

(C)  review, at least monthly, by the treatment/habilitation team that approved the planned intervention.

► In New York, policies and procedures regarding the ordering and use of physical restraints and the recording, reporting, monitoring and review and modification thereof are:
(i) incorporated into the in-service education programs of the facility, with changes made in such programs when policies and procedures are modified; and
(ii) made known to all medical, nursing and other appropriate resident care personnel in advance of implementation.
(5) When physical restraints are used the resident is: (i) released as frequently as necessary to meet resident care needs, but at least every two hours except when asleep in bed, then released as indicated by the type of restraint and by the residents' condition; (ii) provided with changes of position, ambulation or exercise at the time of release; and iii) observed at least as frequently as at the time of dressing and undressing for any evidence of adverse effects, including but not limited to circulatory problems or skin abrasions.
(6) In an emergency situation a physical restraint may only be used if it is: i) approved by the medical director, attending physician or nursing director, or in his or her absence, by a registered professional nurse; ii) used for that specific emergency and for a limited period of time with physician consultation regarding the physical measure or safety device obtained within 24 hours; iii) applied under the direction of a licensed nurse who documents in the clinical record the circumstances necessitating the physical restraint and the resident's response; and (iv) monitored frequently by a licensed nurse until the resident is seen by a physician,
(7) There are written policies specifying and defining each type of physical restraint that is acceptable and available in the facility and the purposes for which each shall be used.

Chemical Restraints    (TOP)    (NEXT)

We found more detail in State regulations on physical than chemical restraint, perhaps because unnecessary medication use is often defined as part of quality of care. Some States group physical and chemical restraints together in its prohibitions and restrictions of use. Ordinarily, however, when chemical restraints are addressed, special definitions and requirements are included that are specific to chemical restraints. In Colorado, a chemical restraint is defined as a medication applied, ingested, or injected for the purpose of altering or controlling behavior. Any medication that can be used both to treat a medical condition and to alter or control behavior shall be evaluated to determine its use for the resident. If a medication is used solely or primarily to treat a medical condition, it is not considered a chemical restraint. In Minnesota, chemical restraints mean any psychopharmacologic drug that is used for discipline or convenience and is not required to treat medical symptoms. In Nevada, chemical restraints means a psychopharmacologic drug that is not required to treat the medical symptoms of a patient, but is used to discipline a patient or for the convenience of members of the staff of a facility for skilled nursing. Ohio provides a more technical definition: there, chemical restraint means any medication bearing the American hospital formulary service therapeutic class 4.00, 28:16:08, 28:24:08, or 28:24:92 that alters the functioning of the central nervous system in a manner that limits physical and cognitive functioning to the degree that the resident cannot attain the resident's highest practicable physical, mental, and psychosocial well-being.

Standing orders or p.r.n. orders (take as needed) are sometimes prohibited for classes of medications that are sometimes used to control behavior. Psychoactive drugs, including antipsychotic drugs may have limited renewals without a new prescription. In Alaska, the resident's medical record must contain evidence of an interdisciplinary team's periodic reassessment of the restraint or psychoactive drug to determine its effectiveness and appropriateness for continued use. In Florida, 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 in Florida who are receiving medications that can serve as chemical restraints must be evaluated by their physician at least annually to assess: the continued need for the medication, the level of the medication in the resident's blood, and the need for adjustments in the prescription. Illinois and Maryland are examples with substantial detail, with the former including a long section on what constitutes unnecessary medication use.

► In Illinois, a) A resident shall not be given unnecessary drugs in accordance with Section 300.Appendix

F. In addition, an unnecessary drug is any drug used:

1) in an excessive dose, including in duplicative therapy;

2) for excessive duration;

3) without adequate monitoring;

4) without adequate indications for its use; or

5) in the presence of adverse consequences that indicate the drugs should be reduced or discontinued. (Section 2-106.1(a) of the Act)

b) Psychotropic medication shall not be prescribed or administered without the informed consent of the resident, the resident's guardian, or other authorized representative. (Section 2-

1(b) of the Act) Additional informed consent is not required for reductions in dosage level or deletion of a specific medication. The informed consent may provide for a medication administration program of sequentially increased doses or a combination of medications to establish the lowest effective dose that will achieve the desired therapeutic outcome. Side effects of the medications shall be described.

c) Residents shall not be given antipsychotic drugs unless antipsychotic drug therapy is necessary, as documented in the resident's comprehensive assessment, to treat a specific or suspected condition as diagnosed and documented in the clinical record or to rule out the possibility of one of the conditions in accordance with Section 300.Appendix F.

d) Residents who use antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue these drugs in accordance with Section 300.Appendix F.

e) For the purposes of this Section:

1) "Duplicative drug therapy" means any drug therapy that duplicates a particular drug effect on the resident without any demonstrative therapeutic benefit. For example, any two or more drugs, whether from the same drug category or not, that have a sedative effect.

2) "Psychotropic medication" means medication that is used for or listed as used for antipsychotic, antidepressant, antimanic or antianxiety behavior modification or behavior management purposes in the latest edition of the AMA Drug Evaluations (Drug Evaluation Subscription, American Medical Association, Vols. I-III, Summer 193), United States Pharmacopoeia Dispensing Information Volume I (USP DI) (United States Pharmacopoeial Convention, Inc., 15th Edition, 195), American Hospital Formulary Service Drug Information 195 (American Society of Health Systems Pharmacists, 195), or the Physician's Desk Reference (Medical Economics Data Productson Company, 49th Edition, 195) or the United States Food and Drug Administration approved package insert for the psychotropic medication. (Section 2-106.1(b) of the Act)

3) "Antipsychotic drug" means a neuroleptic drug that is helpful in the treatment of psychosis and has a capacity to ameliorate thought disorders.

(Source: Added at 20 Ill. Reg. 12160, effective September 10, 196)

► In Maryland, when a physician prescribes psychopharmacologic drugs for a resident, the resident's clinical records shall contain all of the following documentation:

(1) A physician's indication that the dosage, duration, indication, and monitoring are clinically appropriate and the reasons why they are clinically appropriate;

(2) Indication that the resident is being monitored for adverse complications of the drug therapy;

(3) Confirmation that previous attempts at dosage reduction have been unsuccessful, if applicable;

(4) Evidence of the resident's subjective or objective improvement, or maintenance or function, while taking the medication;

(5) Evidence that the resident's decline or deterioration, if applicable, has been evaluated by the interdisciplinary team to determine whether a particular drug, a particular dosage, or duration of therapy may be the cause;

(6) Evidence of why the resident's age, weight, or other factors would require a unique drug dose, drug duration, indication, or monitoring; or

(7) Other evidence that substantiates the use of the restraint.

Abuse    (TOP)    (NEXT)

Some States have added to the comprehensive federal categories on abuse. Hawaii, for example, refers to the residents' right not to be humiliated, harassed, injured or threatened. States sometimes offer further definition of what constitutes sexual abuse or financial abuse. For instance, Illinois defines sexual abuse as sexual penetration, intentional sexual touching or fondling, or sexual exploitation (i.e., use of an individual for another person's sexual gratification, arousal, advantage, or profit). Users of the website should refer to the individual State policies identified in the table below to find additional language around abuse.

Typically, State-specific provisions refer to grievance procedures, procedures to investigate alleged abuse, requirements to keep the individuals involved safe after the allegation of abuse, and mandated time periods for conducting the investigation and reporting to the State. Occasionally immunity is established to those who report abuse in good faith, and/or penalties for those who do not. Occasionally appeal rights are specified for the individual accused of being abusive. Maryland offers particularly detailed rules, which include details of required reporting, time periods, duties of the facility personnel, penalties, and immunity. Massachusetts provides a great deal of detail on the definitions and reporting of abuse, drawn from a general statute that pertains to hospital patients and residents or clients of numerous kinds of programs. Kansas provisions for investigation and reporting, excerpted below, include measures to prevent further abuse while the facility investigates the allegations. In most cases of State rule, the regulations incorporate minimum time periods for investigation and reporting.

► In Kansas, the facility shall:

(1) Not use verbal, mental, sexual, or physical abuse, including corporal punishment, or involuntary seclusion;

(2) not employ any individual who has been identified on the state nurse aide registry as having abused, neglected, or exploited residents in an adult care home in the past;

(3) ensure that all allegations of abuse, neglect, or exploitation are investigated and reported immediately to the administrator of the facility and to the Kansas department of health and environment;

(4) have evidence that all alleged violations are thoroughly investigated, and shall take measures to prevent further potential abuse, neglect and exploitation while the investigation is in progress;

(5) report the results of all facility investigations to the administrator or the designated representative;

(6) maintain a written record of all investigations of reported abuse, neglect, and exploitation; and

(7) take appropriate corrective action if the alleged violation is verified.

Table Comparing States    (TOP)

Note: If the States in this table are not hyper-linked, their provisions do not appear to address the topic, and therefore, do not alter the Federal Regulatory scope.  The Table summarizes content on Resident Behavior and Facility Practices by State (with a link to each State's specific language).  Link to a downloadable PDF document containing all State requirements on Resident Behavior and Facility Practices.

483.13 Resident Behavior and Facility Practices

State Goes beyond Federal Regulations? Subjects addressed: How State differs from or expands on Federal Regulations
Alabama Yes Unusual occurrence requirements
Alaska Yes Physical restraints (prescribing, limiting, alternatives); chemical restraints
Arizona Yes Physical restraints (definitions, use), responsibility for reporting allegations of abuse
Arkansas Yes Physical restraints (definitions, use, monitoring), next business day reporting of incidents, internal only reporting procedure, abuse investigation report, restraints,
California Yes Physical restraints (conditions for their use, applying and monitoring restraints, restraint reduction), rules for special treatment program, restraint and seclusion, acceptable forms of restraints, patient rights, unusual occurrences,
Colorado Yes Physical restraints (definitions; conditions for use; orders (MD and RN); monitoring, assessment, and recording; release; bedrails; linens; safety devices), secure units, residents' rights
Connecticut Yes Physical restraints (ordering, time period, monitoring), reportable event(s)
Delaware Yes Physical restraints (recording, minimizing need, removal in emergency), incident reports
District of Columbia Yes Freedom from restraints, incident reports
Florida Yes Physical restraints (definitions and limits to use, bedrails, consent), Chemical restraint (monitoring of blood chemistry), internal risk management and quality assurance program,
Georgia Yes Physical restraints (definitions, conditions of use), resident bill of rights
Hawaii Yes Physical restraints (notification of physician); Abuse (includes residents to be free from "humiliation"), patients' rights
Idaho Yes Resident rights and responsibilities, accident reports
Illinois Yes Physical restraints (definitions), chemical restraints (definitions, management), abuse and abuse reporting, identified offenders, emergency restraints, incident reports, abuse and neglect
Indiana Yes Written notice within 24 hours of abuse, less restrictive measures taken before restraints, restraint use reviewed every 30 days, abuse and neglect, staff treatment of residents
Iowa Yes Physical restraints (definition, physician ordering, nurse monitoring, type-specific limitations, release; in-service education, use for persons with mental retardation); abuse (investigations, reporting, protecting resident during, investigations), personnel histories,
Kansas Yes Physical restraints (Prescription, Use, Documentation) Staff training, Chemical Restraints, Abuse (Investigations, Reporting), reporting abuse, neglect or exploitation of certain persons
Kentucky Yes Follows Federal regulations
Louisiana Yes Complaint process, prohibition against retaliation, statement of rights and responsibilities
Maine Yes Reporting of abuse, neglect or misappropriation of resident property, reporting of abuse, resident rights, restraints, incident and accident reports
Maryland Yes Physical restraints (indications for use, less restrictive alternatives, training, release), Chemical Restraints (medication monitoring and documentation), abuse (reporting, penalties for not reporting, appeals from those penalties, immunity of reporters to civil liability), reports and action required in unusual circumstances, locked doors prohibited
Massachusetts Yes Physical abuse and mistreatment (definitions, reporting registries). (Note: improper physical restraint is a form of mistreatment.), verbal reports of incidents confirmed in writing in 48 hours, safety and personal protection, extensive scope of reporting, content of report of suspected cases of abuse, protection of reporting person, availability of reports and disclosure, adoption of preventive policies, penalty for patient abuse, procedures for hearings
Michigan Yes Physical restraints (physician prescribing, consulting with physician, chemical restraints (consulting with a physician), accident records and incident reports,
Minnesota Yes Physical restraints (releasing monitoring), Chemical restraints (for both physical and chemical restraints, east restrictive alternatives, emergency applications, informed consent, documentation), incident and accident reporting
Mississippi Yes Physical restraints (physician countersigning of order in 24 hours)
Missouri Yes Resident rights, least restrict restraints
Montana Yes Facility policy requirements, staff training requirements on restraint use, neglect, sexual abuse
Nebraska Yes Criminal background checks, complaints and grievances
Nevada Yes Physical restraints (brief definition), Chemical restraints (brief definitions), prohibition of certain practices
New Hampshire Yes Duties and responsibilities to document incidents, personnel hiring, types of restraints
New Jersey Yes Physical restraints (policies), Chemical restraints (policies), Interdisciplinary team Staff education, mandatory resident rights, mandatory notification, guidelines for management of inappropriate behavior and resident to resident abuse, guidelines for use of restraints
New Mexico Yes Physical restraints (definition, physician orders, time intervals), employee abuse of residents, physical and chemical restraints
New York Yes Physical restraints (definition, authorization, least restrictive alternatives, application, monitoring, release, documentation), Abuse (employment practices, reporting).
North Carolina Yes Physical restraints (definitions, prescription, use, release, documentation); Seclusion and time-out (detailed definitions and rules, authorization, time limits), reporting and investigating abuse
North Dakota Yes Physical restraints, chemical restraints, (For each, a brief statement on physician authorization and limited time period; licensed nurse only applies chemical restraints), report abuse
Ohio Yes Physical restraints (definitions, authorization, least restrictive types, choice appropriate to resident's body and physical condition, justification, time limits); Chemical Restraints (definition, authorization time limits), Locked dementia care units; Seclusion, qualifications of health personnel, prone restraints, transitional hold
Oklahoma Yes Physical restraints; Chemical restraints. (Note, brief statement of physician prescription, time periods, and nursing roles, report abuse to state and federal agencies, incident reports
Oregon Yes Physical restraints (definitions, use and release), chemical restraints; (For both physical and chemical restraints, physician order, emergency use, care planning); Freedom of choice and consent; right to take risks of falls, reduced payment for abuse, resident rights, immunity and prohibition of retaliation,
Pennsylvania Yes Staff development, restraints,
Rhode Island Yes Physical restraints (physician order, emergency use, agreement of resident, family, and/or guardian for continued use to enhance independence); (Abuse) grievance mechanism required and linked to freedom from abuse, personnel criminal check, reporting of resident abuse
South Carolina Yes Physical restraints, Chemical Restraints. (Note: brief allusion to orders by a physician, staff members no prior conviction
South Dakota Yes Restraints
Tennessee Yes Records and list of incidents requiring reports, resident rights
Texas Yes Restraints and seclusion, reports of abuse and neglect, contents of reports, anonymous reports, investigation of reports, confidentiality, immunity, central registry, retaliation, reports relating to resident deaths
Utah Yes Restraints, resident rights, staff and personnel
Vermont Yes Physical restraints (release times, Chemical Restraints (for both physical and chemical restraints, physician orders); Residents informed of policies, including grievance procedure and right of appeal, reports to licensing agency, resident rights
Virginia Yes Complaint investigation, restraint usage
Washington Yes Physical restraints (physicians order, time limits, conditions of use and release; non-emergency use based on interdisciplinary team, chemical and physical restraints, prevention of abuse, resident protection program definition. Investigation, findings, hearings, appeals, required notification, disqualification from nursing home employment, retaliation and discrimination
West Virginia Yes Restraints, documentation, abuse, human resource responsibilities, inspections and investigations, behavior managements special dementia care units
Wisconsin Yes Physical restraints (physician authorization, time limits, documentation, brief definitions), rights,
Wyoming Yes Grievance investigations to review allegations

Complete Transcript of State Requirements on Resident Behavior and Facility Practices (PDF)    (TOP)

Sub-sections of
Resident Behavior and Facility Practices

Physical Restraints

Chemical Restraints

Abuse