It seems like everything is coming to a head at the local nursing home. A reporter called the nursing homeadministrator, told him that the nursing home had a restraint rate of 8% compared to a national rate of 2% and asked him why? The administrator was caught off guard and said he’d call back. He called the DON and asked her why the rate was high. The DON said it was a coding problem, that the number of restraints in the nursing home was really “just average.” The administrator then called the MDS coordinator and asked her. She said that all the restraints were coded correctly and that she had just taken a course from the state’s MDS training coordinator. She said that she saw in medical record that the families wanted the restraints. The administrator went to the person who did QA in the nursing home and asked her what the scoop was. She knew the restraint rate was high, but said it was because all of the residents had hard-to-manage behavioral issues and the restraints were all appropriate.

Whoa… the administrator did not know what to do. It’s coding, it’s the families,it’s the type of residents. Everyone had a different explanation.

The administrator called the DON, QA staff person, MDS coordinator, a few CNAs, Social Worker and Medical Director together for an afternoon pow-wow. The first ten minutes of the meeting were chaotic. It was clear that no one in the nursing home had a handle on the apparent high use of restraints. The only real piece of information the staff had was the CMS Quality Measure and that info was 6 months old.

No one in the group knew quite what to do. The QA person said they had a good QA program and no one had cited them. They really had not looked at restraints in their QA program.

Someone had heard of the Advancing Excellence in America’s Nursing Homes Campaign and suggested they check it out. They did, and sure enough, they found a roadmap that could help them.

  • First, they verified that the data that the reporter had was correct. They went to the section on the AE website called PROGRESS, then NURSING HOMES. They clicked on the PUBLIC INFO button, clicked on their state and then the name of the nursing home. Sure enough, a series of restraint rates and a trend graph popped up. And, sure enough, the restraint rate was higher than the rest of the nursing homes in the state and in the country. It had been for some time.
  • The administrator wanted specifics. Which residents had restraints and why? He now had to explain to the outside world why his rate was so high, and no one in the nursing home had an answer.
  • The staff searched around the Advancing Excellence Website and found RESTRAINTS under the RESOURCES section. There was a data collection tool there that would allow the nursing home to collect information on each resident with a restraint. The MDS coordinator agreed that she could go back in time and count the number and kinds of restraint that were in use.
  • The DON, CNAs and other care giving staff said that they could take a look at the residents, assess them to see the reasons for the restraints, and put this information together in a systematic way. They would look at coding, family involvement, behavioral issues and interventions that had been tried.

Two weeks went by and the new “Restraint Team” met again. This time, staff walked into the meeting armed with info. There were 156 residents in-house and 16 of them were using restraints. The number was actually higher than the reporter had said!

  • It was true that a few restraints were miscoded and one family wanted restraints to “protect” the resident. Staff had reassessed the other residents and determined that by adding other interventions, they could immediately and safely remove restraints in about a third of the residents. They had already reduced the number significantly!
  • The staff found other tools and helpful information on the AE website –
  • An Implementation Guide and Process Framework that walks through the QA/PI evaluation steps for residents with restraints – how to assess each resident, how to determine the cause or reason for restraints, a description of different interventions, and then monitoring techniques to prevent restraint usage in the future,
  • A fact sheet for families that showed that restraints can actually be more harmful than not using restraints, and
  • Tips for the CNAs to use at the bedside to prevent restraint usage.

After a long discussion, they determined that one reason for the high restraint use was high staff turnover (more than90%) and rotating staff assignments on each of the units. By stabilizing the staff and building relationships between the staff and residents, they hoped to impact the use of restraints. They noted that the AE Campaign offers resources to stabilize staff and implement consistent assignment. They decided to join the AE Campaign to take full advantage of the resources and to track their progress on the Campaign website. They agreed to work on two other AE goals, Staff Turnover and Consistent Assignment, in addition to Restraints.

The team resolved to continue using the AE Restraint Tracking Tool and to discuss their progress at the newly formed monthly QI meetings. They also decided to reduce their restraint usage to 2% within the next six months and set their improvement target goal on the campaign website.

Fortunately, the reporter never called back. However, the nursing home staff were proud of how they helped the residents and would be ready the next time he called!