1. ELIMINATING RESTRAINTS IN ASSISTED LIVING Presented by Jim Tiffany

2. Perception YELLOW BLUE ORANGE BLACK RED GREEN PURPLE YELLOW RED ORANGE GREEN BLACK BLUE RED PURPLE GREEN BLUE ORANGE Perception

4. Resident Rights R9-10-710.D.3. A licensee shall ensure that a resident has the following rights: R9-10-710.D.3. A licensee shall ensure that a resident has the following rights: To be free from abuse, neglect, exploitation, and physical restraints and chemical restraints; To be free from abuse, neglect, exploitation, and physical restraints and chemical restraints;

5. Definitions R9-10-701.80. "Physical restraint" means the confinement of a resident or the use of any article, device, or garment that cannot be removed by a resident, used to restrict movement, and control the resident's behavior. R9-10-701.80. "Physical restraint" means the confinement of a resident or the use of any article, device, or garment that cannot be removed by a resident, used to restrict movement, and control the resident's behavior. R9-10-701.21. "Chemical restraint" means any medication that is administered for purposes of discipline or convenience and is not required to treat a resident's medical symptoms. R9-10-701.21. "Chemical restraint" means any medication that is administered for purposes of discipline or convenience and is not required to treat a resident's medical symptoms.

6. Exceptions There are NOEXCEPTIONS!

7. “It depends…” Whether or not an article of clothing or a device is a restraint or a hazard for a particular resident depends on a number of factors, including the resident’s physical ability, cognition, the reason the device is being used, etc., etc, etc… Whether or not an article of clothing or a device is a restraint or a hazard for a particular resident depends on a number of factors, including the resident’s physical ability, cognition, the reason the device is being used, etc., etc, etc…

8. Remember… It is YOUR RESPONSIBILITY to protect the residents in your facility. It is YOUR RESPONSIBILITY to protect the residents in your facility. If residents are at risk for falling, you must take steps to ensure their safety. If residents are at risk for falling, you must take steps to ensure their safety.

10. Bed Rails Between January 1, 1985 and January 1, 2008, FDA received 772 incidents of patients caught, trapped, entangled, or strangled in beds with rails. The reports included 460 deaths, 136 nonfatal injuries, and 176 cases where staff needed to intervene to prevent injuries. Most patients were frail, elderly or confused. Between January 1, 1985 and January 1, 2008, FDA received 772 incidents of patients caught, trapped, entangled, or strangled in beds with rails. The reports included 460 deaths, 136 nonfatal injuries, and 176 cases where staff needed to intervene to prevent injuries. Most patients were frail, elderly or confused. Source: FDA website Source: FDA website

11. Bed Rails Patients at highest risk for entrapment are older or frail adults and those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, or acute urinary retention. These conditions make them likely to move about in the bed or try to get out of it. Patients at highest risk for entrapment are older or frail adults and those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, or acute urinary retention. These conditions make them likely to move about in the bed or try to get out of it. Source: FDA website Source: FDA website

12. Minnesota’s Success Push to remove bed rails by state regulators began in mid-1990s Push to remove bed rails by state regulators began in mid-1990s Nursing homes were fined aggressively – in some cases up to $70,000 for not protecting residents. Nursing homes were fined aggressively – in some cases up to $70,000 for not protecting residents. Dialogue statewide resulted in increased awareness, increased provider and family knowledge. Dialogue statewide resulted in increased awareness, increased provider and family knowledge. Since 1995, the number of nursing home patients using bed rails has plummeted from 14,2000 to fewer than 500. Some patients fall more often, but the number of serious injuries has declined. Since 1995, the number of nursing home patients using bed rails has plummeted from 14,2000 to fewer than 500. Some patients fall more often, but the number of serious injuries has declined.

13. MYTHS AND FACTS: BED RAILS MYTH Bed Rails are a safe and effective means of preventing patients from falling out of bed. FACT “The potential for serious injury is more likely from a fall from a bed with raised side rails, than…where side rails are not used.” (Source: The Centers for Medicare and Medicaid Services) In Minnesota, after a campaign to reduce bed rail use, it was found that some patients fall more often, but the number of serious injuries has declined.

14. MYTHS AND FACTS: BED RAILS MYTH Partial bed rails are not restraints. FACT Partial rails may assist one resident to enter and exit the bed independently while acting as a restraint for another.

15. MYTHS AND FACTS: BED RAILS MYTH “But this resident needs bed rails or he/she will fall.” FACT Alternatives include: Alternatives include: –Low-height beds –Floor mats –Motion sensors –Bed alarms –Individualized toileting schedules –Adequate pain control –Individualized activity programs

18. Criteria test for Physical Restraints Potential physical restraints are observed during the tour of the facility. Potential physical restraints are observed during the tour of the facility. Questions to ask: Questions to ask:  A. Can the resident remove the garment or device without help?  If YES, it is not a physical restraint  If NO, proceed to question B  B. Is the garment or device used to restrict movement?  If NO, it is not a physical restraint  If YES, proceed to question C  C. Is the garment or device used to control behavior?  If NO, it is not a physical restraint  If YES, it is a PHYSICAL RESTRAINT In order to cite as a physical restraint: In order to cite as a physical restraint: ALL 3 conditions must be met. ALL 3 conditions must be met.

19. Physical Restraint or Hazard – Scenario 1 The Surveyor observes an 83 y/o resident laying in bed. There are full-length rails on both sides of the bed, and both rails are in the up position. The Surveyor observes an 83 y/o resident laying in bed. There are full-length rails on both sides of the bed, and both rails are in the up position. The manager says that the resident needs the rails to keep him from falling out of bed. The manager says that the resident needs the rails to keep him from falling out of bed. Is this a restraint? A hazard? Is this a restraint? A hazard?

20. Physical Restraint or Hazard – Scenario 2 The Surveyor observes an 83 y/o resident laying in bed. There are full-length rails on both sides of the bed, and both rails are in the up position. The Surveyor observes an 83 y/o resident laying in bed. There are full-length rails on both sides of the bed, and both rails are in the up position. The Surveyor asks the resident if she can lower one of the rails. The resident does not respond. The Surveyor asks the resident if she can lower one of the rails. The resident does not respond. The manager states that the resident cannot lower the rails, and that the rails are in place because the family is concerned that she may fall out of bed in her sleep. The manager states that the resident cannot lower the rails, and that the rails are in place because the family is concerned that she may fall out of bed in her sleep. Is this a restraint? A hazard? Is this a restraint? A hazard?

21. Physical Restraint or Hazard – Scenario 3 The Surveyor observes an 83 y/o resident laying in bed. There are full-length rails on both sides of the bed, and both rails are in the up position. The Surveyor observes an 83 y/o resident laying in bed. There are full-length rails on both sides of the bed, and both rails are in the up position. The Surveyor asks the resident if she can lower one of the rails. The resident does not respond. The Surveyor asks the resident if she can lower one of the rails. The resident does not respond. The manager states that the resident cannot lower the rails, and that the rails are needed because the resident has a history of trying to get out of bed during the night and falls. The manager states that the resident cannot lower the rails, and that the rails are needed because the resident has a history of trying to get out of bed during the night and falls. Is this a restraint? A hazard? Is this a restraint? A hazard?

22. Online Resources http://www.azdhs.gov/als/hcb/index.htm http://www.azdhs.gov/als/hcb/index.htm http://www.azdhs.gov/als/hcb/index.htm Frequently Asked Questions Frequently Asked Questions License renewal application License renewal application Survey tool Survey tool Caregiver/manager training programs Caregiver/manager training programs Facility Directory, including Statements of Deficiencies and Enforcement actions Facility Directory, including Statements of Deficiencies and Enforcement actions Informal Dispute Resolution (IDR) Process Informal Dispute Resolution (IDR) Process Links to rules, statutes, and enforcement actions Links to rules, statutes, and enforcement actions

23. Online Resources The Arizona Board of Examiners of Nursing Care Institution Administrators and Assisted Living Facility Managers. The Arizona Board of Examiners of Nursing Care Institution Administrators and Assisted Living Facility Managers. http://www.nciabd.state.az.us/ http://www.nciabd.state.az.us/ http://www.nciabd.state.az.us/ Approved continuing education programs Approved continuing education programs Directory of certified managers Directory of certified managers Enforcement actions Enforcement actions Links to rules and statutes Links to rules and statutes Application forms: Initial, renewal, duplicate Application forms: Initial, renewal, duplicate

24. QUESTIONS QUESTIONS Phoenix main: 602-364-2639 Phoenix main: 602-364-2639 Fax:602-364-4766 Tucson main:520-628-6965 Fax:520-628-6991 Fax:520-628-6991 Flagstaff: 928 226-0156 Fax:928 774- 2830 Fax:928 774- 2830 – www.azdhs.gov/als/hcb www.azdhs.gov/als/hcb Thank You