POLICY STATEMENT.

The Division of Veterans Healthcare Services (DVHS) requires that each of the New Jersey Veterans Memorial Homes (VMH) establish and implement protocols guiding the use of restraints to include, but not be limited to: alternatives; use of least restrictive to most restrictive; delineations for limited indications for use; contraindications; the prevention of abuse; and identification of restraints approved for facility use.

PURPOSE.

To ensure veteran home residents are free from chemical and physical restraints, safe from imminent personal harm inflicted by others, and/or unable to inflict harm to others when other means of control are not effective or appropriate; or to prevent serious disruption of treatment or significant damage to the physical environment.

DEFINITIONS.

PHYSICAL RESTRAINT - is 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 his or her body. Bed rails and vest restraints are examples of physical restraints. (NOTE: The resident has a right to be free from any chemical or physical restrains imposed for purposes of discipline or convenience. When a restraint is applied or used, the purpose of the restraint is reviewed and is justified as a therapeutic intervention.)

CHEMICAL RESTRAINT - is the inappropriate administration and/or utilization of a sedating psychotropic drug to manage or control behavior.

DATA COLLECTION – means the routine, continuous gathering of information relating to the use of any physical or chemical restraints in the VMH.

INFORMED CONSENT - means a formal expression, oral or written, of agreement with a proposed course of action by an individual who has the capacity, the information and the ability to render voluntary agreement on their behalf or on the behalf of another.

INTERDISCIPLINARY TEAM (IDT) – is defined as a group of VMH staff members representing nursing, medical, administration, dietary, social services, and activities that meet on a regular and ongoing basis to develop, review, and revise policies and procedures for the use of restraints. The IDT assures that the VMH continuously attempts to eliminate the need for restraints. The IDT, in conjunction with the VMH Quality Assurance Department, continuously monitors the daily use of all types of restraints in the VMH. The IDT is under the direction of a registered nurse (RN).

PROCEDURE.

A. The New Jersey Veterans Memorial Homes (VMH) will establish written policies and/or procedures for the use of restraints, which shall address the following protocols:

a. The use of alternatives to restraints, such as staff or environmental interventions, structured activities or behavior management. Alternatives should be utilized whenever possible to avoid the use of restraints;

b. The use and documentation of a progressive range of restraining procedures from the least restrictive to the most restrictive;

c. A delineation of indications for use, which should be limited to:

i. Prevention of imminent harm to the resident or other persons when other means of control are not effective or appropriate; or

ii. Prevention of serious disruption of treatment or significant damage to the physical environment;

d. Contraindications for restraint use to include, at the very least, clinical contraindications, convenience of staff, or discipline of the resident;

e. Identification of restraint applications approved for use in the facility, which shall be limited to methods and mechanical devices that are specifically manufactured for the purpose of physical restraint. Locked restraints, double restraints on the same body part, four-point restraints, and confinement in a locked or barricaded room is prohibited;

f. Practices for informing the resident and obtaining consent when clinically feasible, and documenting the consent in the resident’s record;

g. Practices for notifying the family or guardian, obtaining consent if the resident is unable to give consent, and documenting the consent in the resident’s record; and

h. Practices guiding the removal of restraints when goals have been accomplished.

B. Interdisciplinary Team (IDT) - or an equivalent shall develop, review at least annually, modify as needed, and ensure implementation of written policies and procedures for the use of restraints and ensure that the VMH continuously attempts to eliminate the need for restraints. Guidance for these policies and procedures is provided in Appendix D of N.J.A.C. 8:39 Standards for Licensure of Long Term Care Facilities.

C. Data Collection - shall include the collection of the following data:

a. All emergency restraint applications.

b. Indicators for the frequency of the use of restraints in the facility.

c. Evaluation of all cases in which there is:

i. A failure to obtain or receive a physician’s or advance practice nurse’s order;

ii. A negative clinical outcome.

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

PROTOCOLS FOR THE APPLICATION OF EMERGENCY RESTRAINTS.

A. Initiation of Emergency Restraints:

a. Only licensed staff shall be authorized to initiate the use of emergency restraints;

b. The application of restraints shall begin with the least restrictive alternative that is clinically feasible;

c. Emergency restraints shall be used only when the safety of the resident is endangered, or there is imminent risk that the resident will cause substantial harm or damage to others or to the physical environment;

d. The facility shall notify the attending physician or advanced practice nurse or another designated physician, and request an order within two hours;

e. The facility shall obtain a physician’s or advanced practice nurse’s order within eight hours of the application of an emergency restraint;

f. Licensed nursing personnel shall evaluate and document the physical and mental condition of the resident in an emergency restraint at least every two hours;

g. There shall be an assessment of the resident by a Registered Professional Nurse within 24 hours; and

h. Continuation of emergency restraints shall occur upon physician or advanced practice nurse orders, which shall be renewed ever 24 hours to a maximum of seven days.

B. Continuation of Emergency Restraints - The VMH shall continuously attempt to remediate the resident’s condition to eliminate or lessen the need for restraints. If the use of restraints is needed beyond one week, at least the following should be done:

a. The need for continued use of restraints shall be implemented only as part of the physician’s medical care plan; and

b. Every resident in restraints shall be assessed by a Registered Professional Nurse at least every 48 hours for the continued use of restraints; and

c. After remediation attempts, there shall be an interdisciplinary review of the record of any resident whose assessment indicates the need for continued use of restraints. This review shall occur within 30 days of the initiation of the use of restraints.

C. Continuation Beyond 30 Days - Continuation of the use of restraints beyond 30 days shall occur only upon written approval of the Interdisciplinary Team (IDT), or its equivalent, and shall include at the very least the following actions:

a. The Registered Professional Nurse shall assess the need for continued restraints at least weekly; and

b. An Interdisciplinary Team (IDT) review shall be conducted at least every 30 days to approve the continued use of restraints.

D. Written Policies and Procedures - The VMH shall have written policies and procedures to ensure that interventions while a resident is restrained are performed by nursing personnel in accordance with the nursing scope of practice as set forth by the New Jersey Board of Nursing.

The policies and procedures shall include at least the following:

a. Periodic visual observations shall be performed with the following frequency:

i. Continuously, if clinically indicated by the resident’s condition; or

ii. At least every 15 minutes while the resident’s condition is unstable; and

iii. Thereafter at least every one to two hours, based upon an assessment of the resident’s condition.

b. Release of restraints at least once every two hours in order to:

i. Assess circulation;

ii. Perform skin care;

iii. Provide an opportunity for exercise or to perform range of motion procedures for a minimum of five minutes for each restrained limb, and for repositioning;

iv. Assess the need for toileting and assist with toileting or incontinence care;

v. Ensure adequate fluid intake;

vi. Ensure adequate nutrition through meals at regular intervals, snacks, and assistance with feeding if needed;

vii. Assist with bathing as required at least daily; and

viii. Ambulate at least once every two hours, if clinically feasible.

E. Interventions for Overnight Sleeping - The Facility shall have written policies and procedures for interventions by nursing personnel for residents in restraints for overnight sleeping. These policies and procedures shall include at least the following and shall be implemented in accordance with the nursing scope of practice, as set forth by the New Jersey Board of Nursing:

a. Visual observation based on the resident’s condition, occurring at least every one to two hours;

b. Administration of fluids as required;

c. Toileting as required;

d. Release of restraints at least once every two hours for repositioning and skin care, if clinically indicated; and

e. Prohibition of any method of restraint that places the resident at clinical risk for circulatory obstruction.

F. Training in the Use of Restraints - All nursing and professional staff of the facility shall receive orientation and annual training in the use of restraints, including at least:

a. Emergency and non-emergency restraint procedures;

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

c. Interventions by licensed and non-licensed nursing personnel; and

d. Types of restraints in use at that particular VMH.

G. The Quality Improvement Program shall monitor trends in the use of restraints in accordance with the Standards for Licensure of Long-Term Care Facilities, set forth by the New Jersey Department of Health and Senior Services 8:39-33.2 (c) 10.

Revised: April 2007