News Room

One Nursing Home's Journey to Eliminate Restraints

After attending the first session of a statewide restraint collaborative in May 2009, Skies Healthcare and Rehabilitation, LLC, a long-term care facility located in Albuquerque, decided to begin its journey to remove all restraints from its residents and explore new processes aimed at reducing falls. Restraints are any device that either mechanically or psychologically restricts a person’s ability to move on his or her own. Examples of restraints include waist belts, geri-chairs, hand mitts, lap trays and siderails. An audible alarm that is set off when a person moves is also considered to be a restraint. Restraints have been identified as a potential hazard for residents that can lead to loss of mobility, depression, isolation and even death from strangulation.

Skies Healthcare is one of 23 facilities in New Mexico working with the New Mexico Medical Review Association (NMMRA) to improve the quality of care provided to residents by reducing the use of restraints. Under its Quality Improvement Organization (QIO) contract with the Centers for Medicare & Medicaid Services (CMS) and as part of the National Patient Safety Initiative, NMMRA provides technical and professional guidance to nursing homes like Skies Healthcare to improve the rates of specific quality indicators that are publicly reported on the Medicare Web site Nursing Home Compare at www.medicare.gov/nhcompare/.

Skies Healthcare made several discoveries along its journey to reduce restraint use. The facility had been using alarms to help reduce fall risk, but decided that this method was not effective because help arrived too late and falls were still occurring.

In May 2009, the facility joined the restraint collaborative, called “Breaking the Ties That Bind: How to Keep Your Residents Safe Without Restraints,” a project coordinated by NMMRA and supported by an advisory committee that includes representatives from the New Mexico Health Care Association and the New Mexico Department of Health, Health Facility Licensing and Certification Bureau, among others. As a result of its involvement in the collaborative, some of the changes made by Skies Healthcare included:

• The implementation of a no-restraint policy supported by all facility leadership
• Meetings and inservices with certified nursing assistants (CNAs) and other staff to provide education and solicit feedback and ideas
• Sending a letter to the families of the residents explaining that the facility would no longer use restraints
• Testing the changes starting with just one resident to determine what worked best before expanding change facility-wide
• Making several facility adjustments such as updating therapy screening forms, providing alternative seat cushions, adjusting wheelchair heights, and beginning walking schedules for residents who tended to fall
• Instituting incentives and rewards for CNAs experiencing fewer falls while on duty
• Adding activity staff while utilizing more volunteers to increase resident activities

Once these changes began, the nursing home found that overall compliance with state requirements improved, as well as its rates on the restraint quality indicator. Skies Healthcare is also experiencing higher morale and more consistent staffing, due in part to its restraint-reduction efforts, and this is leading to financial benefits.

The primary challenges faced by the facility are resistance from family members who insist that their loved ones should continue to be restrained and the ongoing risk of falls. These issues are addressed by continuing to educate families about restraints and by focusing increased attention on falls management.

“It was important that staff have buy-in to the changes being made,” said Jimmy Melton, Skies Healthcare Administrator. “We made it clear that any concern about our new efforts be brought to our Director of Nursing, rather than to family members, so that the message that we are no longer restraining residents and our reasons for this are consistently communicated.”

“We now are learning more about each resident’s habits, and we’re paying attention to the resident’s preferred schedule,” explained Michelle Atencio, Director of Nursing at Skies Healthcare. “We know what they are doing that might lead to a fall. This approach not only helps to reduce the number of falls, our care has become more person-centered.”

After beginning restraint-elimination efforts with one resident on each of its four hallways, Skies Healthcare was ultimately able to eliminate 10 restraints in one month. The facility’s publicly reported, trended data shows a decrease in the number of residents who were physically restrained from 16 percent in the beginning of 2008 to zero for the most recent quarter of data (see graph).

Facility-level quality measure rates are obtained from the Certification and Survey Provider Enhanced Reporting (CASPER) system, which is populated by data from each facility. This data is also available to each facility and is provided by CMS to NMMRA.

“A key to this success is increased communication among everyone involved,” added Atencio. “We have had a restraint rate of zero now for three months.”

According to NMMRA, Skies Healthcare is just one example of a nursing home improving its restraint rate. “Many nursing homes in the state and across the country are improving on this indicator,” says NMMRA Director of Patient Safety Carlene Brown, MPH, CPHQ. As nursing homes become more resident-focused and less institutionally driven, practices such as restraints that are primarily used for the convenience of the staff, not the resident, will continue to disappear.”

To learn more about efforts at Skies Healthcare and Rehabilitation, LLC, contact Michelle Atencio, Director of Nursing, at (505) 898-7986 or dskies@skilledhealthcare.com.

NMMRA also offers additional information about restraints and its work related to restraints on its Web site at www.nmmra.org/providers/nursinghomes_restraints.php, including a guide for residents and families at www.nmmra.org/resources/download.php?id=1864.