JCAHO restraint dilemma muddies fall policies
Patients fall regardless of efforts
The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, released tighter rules for restraint use in July 1996, prompting many health care facilities to reassess their policies. Debbie Foshee, RN, director of quality and risk management at Sacred Heart Hospital in Pensacola, FL, says patient falls still happen, and that patients fall in hospitals with liberal restraint policies as well. Both types of hospitals see injuries from restraints."Restraints don’t promise that patients won’t be injured," she says. "You’re going to get into trouble by going too far in either direction. You’ll get sued for a fall, or you’ll get nailed by the Joint Commission. So you might as well do the right thing, and we think that means respecting the patient and avoiding restraints."
A recent lawsuit demonstrated that restraint policies are no guarantee against injuries from falls or violence, and illustrates the dilemmas health care providers face regarding restraints. Ethicists point out that even a liberal restraint policy is no guarantee against injuries from falls or patient violence — and therefore a potential consult for the ethics committee.
Sacred Heart recently settled a suit alleging that hospital staff did not apply a restraint to a patient even though it was warranted and authorized by a physician. The patient, a stroke victim, had been restrained both chemically and physically at the hospital during previous admissions, according to her attorney.
When she was admitted to the hospital in October 1993 for weakness and difficulty with prescribed medication, she was disoriented and repeatedly got out of bed. A doctor authorized the use of a Posey restraint, but the nursing staff did not apply it. The patient subsequently was found lying on the bathroom floor, where she had fallen and broken her hip. The hospital settled for a confidential amount in February 1997.
The case shows how nurses may not always follow their own facility’s restraint policies according to their assessments of patient needs. Hospital officials say the incident occurred differently and note that the hospital had a rather typical restraint policy in 1993, not the more strict policy in place now.
The nursing staff did, in fact, apply the Posey restraint to the patient, but removed it when her husband protested, says Foshee. Both the patient and her husband were difficult for staff to work with, says Sacred Heart claims specialist Linda McWilliams. She adds that the husband himself had removed the restraint from his wife on previous occasions.
"She was a thin little lady and had gotten out of the Posey before, so the nurses didn’t have any confidence in the restraint anyway," Foshee says. "This shows that no policy and no restraint will ever guarantee that you won’t have a patient fall. They were authorized to use it, they did, and she fell anyway."
Most falls at FirstHealth Moore Regional Hospital in Pinehurst, NC, occur when patients fall out of their wheelchairs during transport, explains Pauline Desjarlais, a nurse manager there. "We found a higher percentage than anticipated of patients who fell even though restrained. Patients remove their restraints. We always use seat belts, but somehow it happens anyway," she says. "In an acute care unit, the typical fall is out of bed."
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