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Clinical Nursing Cases

Physician Restraint Orders Unclear On Transfer, Do You Apply In The Interim?
Tousignant v. St. Louis County, 602 N.W.2d 882 - MN (1999)

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Summary: The use of Mechanical or Physical Restraints on confused patients is highly controversial. Due to substantial Death & Injury attributed to their use they are considered a last resort measure in providing for the safety of a patient. In this case, orders specifying what restraints and when they were to be used were unclear. In a patient that was clearly at high risk for injury, should they have been applied till the physician could have been contacted?

The patient was discharged from the hospital following hip surgery and admitted to the Nursing Home for "rehabilitation."

This is a common occurrence and performed routinely once the patient is considered "stable" enough to go to a Nursing Home but not well enough to go home.

It is much cheaper for a Health Maintenance Organization or Insurance Company to keep a patient in a Nursing Home during their rehabilitation than it is to maintain their care in an Acute Care facility or Hospital.

At the time of the transfer, it had been documented that the patient was confused and unsteady on her feet. She was advised not to ambulate without her walker and identified as at "High Risk for Fall."

"Each year about 12,000 older Americans die as a result of a fall. Falls are the second leading cause of unintentional injury death in the U.S., second to auto accidents, and the leading cause of nonfatal injuries."2

She had a documented history of noncompliance with these instructions that in the hospital necessitated restraint use.

"Restraints may be physical or chemical. Chemical restraint involves the use of psychotropic drugs or sedatives or paralytic agents. Physical restraint involves the use of physical or mechanical devices to restrain movement. Physical restraints may be cloth, leather, metal handcuffs or shackles, car seats, or seat belts."3

The use of Chemical, Physical or Mechanical restraints has for decades been coming under scrutiny. Due to this public outcry, many Nursing Homes have adopted "restraint free" policies.

Restraint use has been strongly tied to abuse, misuse, death and injury. For the Nurse, the use of restraints, minimizes the chances of a patient injuring themselves or others. Judicious use can assist in maintaining control of an otherwise uncontrollable patient.

In situations of Short Staffing, this "control" becomes especially critical as a nurse may be spread thinly between many patients and responsible for the safety of each.

Many a nurse has been injured in the line of duty because a facility either did not support restraint use, a family member may have objected or a physician simply refused to write an order for them.

"Patients and staff in mental hospitals have a right to be free from violent assault, but it must be balanced against the right of patients to be free of unnecessary medication and seclusion. Some staff members fear that whatever approach they take, they will be held legally liable, but both harm and legal damages are likely to be lower if they err on the side of preventing violence."4

When faced with this situation in an already dangerously short-staffed unit, you have a recipe for disaster.

"The Department of Justice "will document a high use of seclusion and restraint and tie this directly into inadequate staffing, inadequate treatment programming, inadequate delivery of rehabilitative services, and finally, into the overuse of psychopharmacologic interventions," Geller wrote."5

Restraints may be applied for only specific situations:

"The use of involuntary mechanical or human restraints or involuntary seclusion is only justified as an emergency safety measure in response to imminent danger to one's self or others. These extreme measures can be justified only so long as, and to the extent that, the individual cannot commit to the safety of themselves and others."6

On the patient's transfer form, two conflicting orders were written regarding the use of mechanical & physical restraints.

One order specified "Apply Vest PRN or AS Needed for confusion."

The other called for their use at all times to provide for the patient's safety.

This was a new patient to the facility and no previous history was provided aside from what was on the transfer documentation.

What was clear, is that the patient had needed restraints in the hospital and that the physicians had written orders to continue their use to provide for the patient's safety. They had been necessitated by "confusion" and "noncompliance" on the part of the patient which made her a "high risk" for injury and fall.

The nurse caring for the patient noted the conflicting orders and attempted to contact the physician. While she was waiting for the physician to respond, the patient was left unrestrained.

This is irregular in that an order did exist for restraints to be applied. The confusion was regarding the duration of use.

The questions arise:

1. Was the patient, on admission, visibly trying to get up and putting herself in harms way. If yes, why weren't restraints applied immediately.

2. Would the prudent nurse have applied the restraints (provided for the patient's interim safety) while waiting for the order to be clarified.

3. When the patient was admitted, how long did it take for the nurse or nurse manager to process the patient and begin the admission procedures?

From personal experience in Nursing Homes I know that when a patient comes in, especially early in the shift, the unspoken priority is to get medications out.

In a Nursing Home, a Licensed Practical Nurse or Registered Nurse can be responsible for fifteen to sixty patients each per shift.

With this assignment to start, processing an admission can turn into an overwhelming task in an already hectic shift.

Frequently starting an admission will need to wait, sometimes hours, before a nurse has time to see and assess the patient. It may be considerably longer before a nurse can start processing orders and making phone calls.

If a Nursing Manager or Supervisor is in the picture, some will assist in beginning the process, most will not. An unspoken law in most facilities is whoever starts an admission, must finish it. It is all too common for it to be "left" for the next shift.

In this particular situation, the nurse did attempt to notify the physician and clarify the orders.

The physician would not respond for several hours following the nurse's attempts to make contact.

During those interim hours, the patient would continue to go unrestrained. During that time period, the patient would be found lying on the floor and injured.

It is important to note, that there was a documented need for restraints to be placed. The ambiguity came with how often they were to be applied.

Why the patient was not put immediately into restraints on admission is unclear.

If a physician cannot be contacted immediately, in a situation involving patient safety, the nurse owes a duty to the patient to pursue the issue further.

The supervisor or administrator on duty should have been notified of the situation immediately.

If the patient had been transferred from a hospital, it is likely the charge nurse at that facility would have information concerning the patient. A phone call to either the nurse caring for the patient prior to the transfer or facility could have provided needed history and avoided the patient's injury.

The physician caring for the patient prior to transfer was familiar with the patient and the need for restraints. Regardless of the fact that the patient was no longer their patient, the prudent physician would have at least clarified the orders.

Nursing Home residents are protected in some states by the Vulnerable Adults Acts.

"A vulnerable adult is any person, 18 years of age or older who: Is a resident or inpatient of a health care facility or Receives services from: A licensed home care provider or A person or organization that provides personal care assistance under the state's medical assistance program."7

As a result of the patient's fall and resulting injuries, an investigator for the state was called in. The investigator happened to be a nurse as well.

In her investigation of the consumer complaint filed, she found substantial evidence that the patient should have in fact been restrained.

In evaluating the complaints of negligence against the nursing home and nursing staff, it was established and documented that the patient clearly should have been restrained.

In the ensuing lawsuit, there was substantial evidence presented by Expert Witnesses to support the need for restraints to provide for the patient's safety.

Unfortunately for the patient, the testimony came too late. By the time the expert witnesses were offered by the plaintiff, the deadline for the submission of testimony and affidavits had expired.

The lawsuit would be dismissed.

On appeal, the appellate court affirmed the judgement of the lower court.

Due to a technicality, the failure of expert testimony to be presented in a timely fashion, no action could be taken against the nurse or nursing home.

It is unfortunate for the patient that the case was dismissed on a technicality. Based on the evidence presented by both the State Investigator and Expert Witnesses, the nurse caring for the patient was clearly negligent.

Related Case Studies:

September 19, 1999: Abusive Psychiatric Patient Restrained, Placed In Seclusion For Angering Nursing & Medical Staff?
Summary: In dealing with violent, abusive or angry psychiatric patients, the safety of the patient and staff are the priority concerns. When restraints or seclusion are deemed necessary, justification for the measures must be documented concisely. In this case, an unruly patient angered the nurse caring for him. When leather restraints were applied and maintained for a prolonged period of time, the patient would object and later sue for damages.
Alt v. John Umstead hospital 479 S.E. 2d 800

August 15, 1999: Violent Psychiatric Patient Attacks Nurse,
No Legal Recourse Against Facility or Psychiatrist?
Charleston v. Larson, 696 N.E. 2d 793 – IL 1998
Summary: It would seem absurd, that if a physician admits and facility assigns a nurse to care for a known violent patient, that it has no legal obligation to protect that nurse against violence. In this case, a psychiatric patient sought admission to facility. On admission, he threatened to attack a nurse. When the patient would follow through on his threat, the nurse was denied legal recourse against the psychiatrist who could have taken precautions against the attack.
http://www.nursefriendly.com/nursing/clinical.cases/081599.htm

August 1, 1999: Nursing Duty To Patient, "Does Not Guarantee" Safety Or Quality Of Care.
Summary: When a nurse accepts report and responsibility for the care of a patient a duty to the patient is also accepted. This duty is to provide a reasonable standard of care as defined by the Nurse Practice Act of the individual state and the facility Policy & Procedures. In this case, a post-op abdominal aneurysm repair patient was injured after falling from his bed to the floor. When a lawsuit was filed the court initially mistook expert testimony to imply the role of the nurse includes a guarantee of safety.
Downey v. Mobile Infirmary Med. Ctr. - 662 So. 2d 1152 (1995).
http://www.nursefriendly.com/nursing/clinical.cases/080199.htm

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Sources:

1. NLRR 9 (February 2000)

2: Bed-Check® Corporation. No Date Given. The Aged and Falls -- Characteristics and Facts. Retrieved October 10, 2000 from the World Wide Web: http://www.bedcheck.com/aged2.html

3. American Academy Of Pediatrics. March 1997. The Use of Physical Restraint Interventions for Children and Adolescents in the Acute Care Setting (RE9713). Retrieved September 19, 1999 from the World Wide Web: http://www.aap.org/policy/re9713.html

4. President and Fellows of Harvard College. 1991. Violence and Violent Patients. The Harvard Mental Health Letter. Retrieved August 15, 1999 from the World Wide Web: http://www.mentalhealth.com/mag1/p5h-vio2.html


5. Martz, Micheal. September 15, 1998. Left Behind / Some Patients Have Been Institutionalized For Years. Richmond Times-Dispatch. Retrieved September 19, 1999 from the World Wide Web: http://gatewayva.com/rtd/special/mentalhealth/mhces15.shtml

6. National Alliance for the Mentally Ill (NAMI). February 17, 1999. Use Of Restraints And Seclusion. Retrieved September 19, 1999 from the World Wide Web: http://schizophrenia.nami.org/update/990217.html

7. Minnesota State Bar Association. No date given. Adult Abuse, Neglect & Financial Exploitation (Maltreatment Of Vulnerable Adults) In Minnesota. Retrieved December 12, 1998 From The World Wide Web: http://www.mnbar.org/adultabu.htm#vuln

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Send comments and mail to Andrew Lopez, RN
Created on October 14, 2000

Last updated by Andrew Lopez, RN on March 23, 2017


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