RESIDENT CARE AND SERVICES MANUAL SECTION: RESIDENT SAFETY INDEX I.D.: E-25. APPROVED BY: REVISED DATE: April 30, 2010

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1 SUBJECT: RESTRAINTS PAGE: 1 OF 6 STANDARD: 1. The decision to use restraints is based on the principle that least restraint can only be considered after the interdisciplinary team had tried alternatives to restraining. Least restraint is defined as the least restrictive measure, used for the shortest duration possible, which allows for the maximum freedom of movement and/or resident s control. 2. An interdisciplinary assessment and appropriate consultation with Resident and/or substitute decision maker will be conducted if a restraint is deemed necessary, and the least restrictive measure shall be used for the shortest duration possible. The only exception to # 2 is in a situation where section 36 of the LTCHA is evoked see A under procedure. 3. The identification of risk factors and the promotion of individual freedom, independence, and dignity will be carefully assessed by the interdisciplinary team in consultation with the Resident and/or substitute decision maker prior to ordering a restraint. 4. A physical restraint is any physical device attached directly to the resident, and used to protect the resident from serious bodily harm to self and/or others as a result of unsafe mobility, agitation, aggression or interference with specific medical treatments. It is considered a restraint ONLY when the resident is unable to undo it due to physical and/or cognitive deficit placed. 5. Physical devices which are defined as restraints: Geriatric chairs and wheelchairs with tabletops in place Lap belts if they are applied in such a fashion that the seat belt opening is placed at the back of the chair and/or the seat belt cannot be undone by the resident 6. Physical devices which are not defined as restraints include: Devices for positioning or limb support Any physical device used as a personal assistance services device (PASD) to assist a resident with routine activity of living.

2 SUBJECT: RESTRAINTS PAGE: 2 OF 6 7. The following physical devices are prohibited (which means cannot use under any circumstances) by the LTCHA Regulation 79/10 and must not be used in the Home: a. Roller bars on wheelchair, commodes and toilets; b. Vest or jacket restraints; c. Any device with locks that can only be released by a separate device such as a key or magnet; d. Four point extremity restraints e. Any device used to restrain a resident to be commode or toilet; f. Any device that cannot be immediately released by staff; g. Sheets, wraps, tensors or other types of strips or bandages used other than a therapeutic purpose. PROCEDURE: A. Restraining a resident under section 36 of the LTHCA the common law duty 1. The common law duty to protect and the LTCHA and Regulation 79/10 place the duty on the caregiver to restrain or confine a resident when immediate action must be taken to prevent serious bodily harm to the resident, other residents or other persons (staff, families, visitors, volunteers and other). 2. When a physical device is being used to restrain a resident pursuant to the common law duty, the following must be followed: a) The resident must be monitored and supervised on an ongoing basis (while restrained) repositioned and released from the restraint when necessary based on the resident s condition or circumstances. b) The resident s condition can only be re-assessed by a physician, RN (EC), RN or RPN. c) The resident must be re-assessed at least every fifteen (15) minutes while restrained pursuant to the common law duty. d) Once it is deemed by the re-assessment that the resident no longer requires to be restrained pursuant to common law duty, the interdisciplinary team must follow all the steps in section B of this policy and section 31 of the LTHCA and section 110 of the Regulation 79/10.

3 SUBJECT: RESTRAINTS PAGE: 3 OF 6 e) Contact the physician or RN (EC) and the substitute decision maker as soon as possible and inform them of the resident s condition that posed an immediate threat to self or others the restraining of the resident pursuant to the common law duty. Obtain an order for the use of the restraint only for the period deemed necessary to protect the resident and/or others form serious bodily injury/harm. f) Document in the electronic progress notes all actions taken and update the care plan as required. B. Restraining by a physical device 1. The interdisciplinary team initiates the assessment process when a situation presents itself that could result in the use of a restraint. The causal factors are assessed, and appropriate interventions/treatment will be implemented by the care team. Document these in the care plan, and electronic progress notes. 2. If the interventions/treatment is not effective, the care team reviews the plan of care and introduces alternative measures to the use of a physical restraint. These are implemented, documented in the care plan, and electronic progress notes, and evaluated to determine effectiveness. 3. If alternative measures prove ineffective, physical restraint use may be considered. An interdisciplinary team conference involving the resident and/or substitute decision maker is held to assess and discuss resident s safety, alternative measures, and the use of physical restraint. Discuss with resident/substitute decision maker, the type of restraint, the risks and benefits of restraint versus no restraint. Documentation of assessment will take place in the Interdisciplinary Restraint Assessment tool and discussion and response to be documented in the electronic progress notes. The care plan is updated to reflect the use/type/reason for the restraints and appropriate interventions implemented to monitor, reassess and record restraint use. The interdisciplinary team, resident and/or substitute decision maker will consider the least restrictive restrain in light of the resident s condition. 4. Obtain informed consent, prior to the application of a physical restraint (except in an emergency situation) from the resident if deemed competent, or from the substitute decision maker if resident has been assessed as incompetent.

4 SUBJECT: RESTRAINTS PAGE: 4 OF 6 C. Initiation of physical restraint use: 1. A physician or RN (EC) must order a physical device and should include: a. The type of physical device b. The reason for the restraint c. When the physical device is to be used (including maximum length of time 1hr while up in chair, etc.) 2. Before applying a physical restraint, reinforce with the resident and/or substitute decision maker the rationale for the restraint, how the restraint will be applied, and the length of time the restraint will be in use. Reassure resident/sdm that resident will be monitored while in the restraint. 3. The nursing staff will apply the physical device according to the manufacturers specifications and as comfortably as possible. The physical device cannot be altered. The nursing staff must ensure that the physical device is well maintained prior to application. D. Ongoing use of a physical restraint: 1. After initial application of the physical device, the nursing staff must monitor every hour (q1h) the resident s safety, comfort, and position of the physical device. This will be documented in POC by the Personal Support Worker staff. The physical device will be released every two hours (q2h) and the resident repositioned. Resident must not be restrained in bed by the application of physical devices except to allow a clinical procedure or interventions that requires the resident s body or a part of the resident s body to be stationary. 2. The decision to continue the use of a physical restraint as well as the type of the restraint shall be re-evaluated by the registered staff (RN/RPN) at least every eight (8) hours. This assessment will be documented on the electronic Medication Administration Record (emar). 3. The type of physical device used to restrain a resident and the orders for application is documented in the electronic progress notes, Physician s orders, and is reviewed at least quarterly by the physician, RN (EC) and registered staff. 4. When the team assesses that the use of a physical device is no longer required, the physical device is discontinued and a physician s/ RN (EC) order should indicate that the use of a restraint has been discontinued. The electronic progress notes include documentation of the reason for discontinuation of the physical device

5 SUBJECT: RESTRAINTS PAGE: 5 OF 6 and time of removal. The resident and/or substitute decision maker is also informed of the discontinuation of the physical device. 5. The interdisciplinary care team must provide post restraining care to promote comfort and safety. 6. Staff can only apply a physical device that has been ordered by the physician or RN (EC). 7. Staff must receive training on the potential dangers of the physical device before applying the device. E. Approved Physical Devices: 1. The Home will only use the following physical devices as a restrain: Seat belts (front fastening or back fastening) Bed rails Lap trays Recliner chairs if reclined more than 30 angle F. Personal Assistance Services Devices (PASD): 1. PASDs may be used to assist a resident with a routine activity on daily living (e.g. bed rails to assist resident in positioning, lap trays to assist resident with meals). 2. If a PASD being used by a resident has the effect of limiting or inhibiting a resident s freedom of movement and the resident is not able to remove it or ask to have it removed, the following must be in place: a) Alternatives to the used of a PASD have been implemented and not effective in assisting the resident with ADL. b) The PASD is reasonable for the resident s condition and the least restrictive PASD is considered. c) The physician, RN, RPN, Occupational Therapist or Physiotherapist can order or approve the use of a PASD. d) The resident and/or substitute decision maker have provided informed consent to the use of the PASD. e) The PASD must be in good condition and must be applied in accordance with the manufacturer s instructions. f) The staff must receive training on the potential dangers of the use of the PASD prior to application:

6 SUBJECT: RESTRAINTS PAGE: 6 OF 6 Key considerations: If the PASD is not removed as soon as the ADL is completed, and the resident has not requested to have it retained, the PASD becomes a physical restraint and all the rules noted in the sections B, C, and D of this policy apply. G. Evaluation: OUTCOME: 1. The restraints used must be analyzed monthly and changes made, if any, based on this analysis. 2. Annually, there must be an evaluation to determine the effectiveness of the restraint and improvements implemented properly to ensure compliance with policy. A record is kept of the monthly analysis and the annual evaluation results and improvement made including the names of the persons who participated. 1. Documentation in the plan of care and care plan reflects the reason for the restraint and regular reassessment. 2. The resident is checked hourly and information documented on the documentation record. 3. There is evidence in the plan of care of an order and consent for the application of the restraint. ADDITIONAL REFERENCES: 1. LTCHA and Regulation 79/ College of Nurses of Ontario, Standards on Restraint Use. 3. Accreditation Canada Standards 4. Forms Manual, Interdisciplinary Restraint Assessment and Consent Form