Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
MINIMIZING RESTRAINTS IN NURSING 
HOMES: A GUIDE TO ACTION 
~t- " 
SERViCes
Richard P. Kusserow 
INSPECfOR GENERAL 
~.t 
OEI -01-91-00840  . - .. . . . . . . . . . . . . . . . . . . . . . . 
................ ...... ....... ...... ....... ....... ...... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...  
TABLE OF CONTENTS

IN1RODUCI10N  .. 1

. . . . . . . . . 3

ESTABliSHING  A COMMITMENT TO RESTRAINT  REDUCI10N 
RES~ 
REDU~G 
......................................... 7

A RESTRAINT- HOME 
MAINTAINING  FREE 
CONCI...USION 
IX A

APPEND 
Methodology ................................................... A-

APPENDIX 

Homes Selected for Site Visits ...................................... B

APPENDIX C 
Bibliography.................................................... C-
 INTRODUCTION
PURPOSE 
In this guide, we aim to assist nursing homes in minimizing the use of physical and 
chemical restraints. Toward that end, we present lessons drawn from the experiences 
of nursing homes that have made progress in reducing restraints. 
BACKGROUND 
Since October I990, the nation s nursing homes have had to comply with a new 
and significant Federal mandate: that nursing home residents have "the right to be 
free" from physical and chemiCal restraints not required to treat their medical 
symptoms. This mandate is part of a sertes of reforms intended to improve the quality 
of care in nursing homes that were enacted by Congress in the Omnibus Budget 
Reconciliation Act of I987 (OBRA-87). 
Congress imposed this requirement because of concerns about widespread use of 
physical and chemical restraints in nursing homes. Both types of restraints restrict a 
person s ability to move about freely. Examples of physical restraints include hand 
mitts, vests that tie residents to their chairs or beds, and restrictive chairs, such as 
gerichairs with lap trays and small wheels that limit mobility. Examples of chemical 
restraints include psychoactive drugs, which control mood and behavior. 
In carrying out the new requirement, nursing homes have faced many operational 
challenges.' Some of these have involved confusion about how restraints are defined. 
Others, probably more consequential, have involved the dynamics of changing long 
established practices--of introducing new routines and ways of thinking about the care 
of nursing home residents. 
MElli 0 DO LOG Y 
In this guide, we report on the lessons learned by nursing homes engaged in 
reducing the use of physical and chemical restraints. We did not evaluate the 
outcomes of their approaches to restraint reduction, nor do we address how the State 
surveyors might interpret their efforts. Rather, we simply report lessons captured 
from their collective experiences. 
The lessons we present come primarily from the experiences of seven nursing 
homes we visited in three States (see appendix B). To a lesser degree, they come 
from telephone and personal 
conversations we held with representatives of other 
homes and of national organizations in the field, and from our review of the published 
literature and guidebooks.  In selecting the seven homes for our on-site case studies, we sought to maximize 
the relevance of their experience to other homes. We did this by 
selecting homes that 
had received no special funds for reducing restraints and that had continuity in their 
nursing and administrative staff. We also chose homes that had some success in 
reducing restraints, that had between 5I and ISO beds, and at least 50 percent 
Medicaid residents. Finally, we chose homes in three States in the Northeast and the 
Midwest to ease our travel arrangements. (See appendix A for more details on our 
methodology. ) 
We present our lessons in three areas that reflect the operational stages of 
restraint reduction. These stages involve (I) es~ablishing a commitment to restraint 
reduction, (2) reducing restraints, and (3) maintaining a restraint-free home. In each 
area, we pose a number of basic questions that we found nursing homes regularly ask. 
Our answers reflect the lessons that those working in the homes we visited have 
learned. In some instances we present our answers sequentially; however, many of the
steps toward restraint reduction require ongoing attention. 
We present our lessons in a question and answer format. We direct these 
questions and answers to those in nursing homes who are leading their homes
' efforts 
to reduce restraints. These leaders may include administrators, nursing directors 
charge nurses, certified nursing assistants, therapists, social workers, activity specialists 
and others. Hereafter, our use of the pronoun "  " in a question refers to the 
leadership within the nursing home, while "  " in an answer refers to the Office of 
Inspector General study team.  , "

ESTABLISHING A COMMITMENT TO

RESTRAINT REDUCTION

We have been using restraints and have always considered ourselves to be providers of 
good care. OBRA is a big change for us. How do we get everyone to want to reduce 
restraints? 
Stress that times have  Both mobility and personal autonomy are 
changed. Just as a physician  threatened by the use of involuntary

no longer routinely removes  restraints. No controlled trial has yet 
a child's tonsils, now we  demonstrated the ability of restraints to 
know that restraints should  prevent injury, but a large body of literature 
no longer be used routinely  attests to their adverse 
effects, rncluding
because their risks- strangulation, increased agitation, and the 
incontinence, stiffness, loss 
many complications of immobilization. 

of bone mass, and  (1.  Francis  Using Restraints in the Elderly Because of Fear 
strangulation, among others- of Litigation,  New Eneland Journal of Medicine 320, no. 
870) 
outweigh their benefits.  13 (1989): 
Stress the residents' quality 
removing restraints  One director of nursing found 
of life:  her staff 
can make them happier and  skeptical about removing physical restraints 
restore their dignity.  safely. She surveyed them confidentially 
using questions from the Kendal 
Have everyone try on a  Corporation  " Untie the Elderly" program. 
She asked about their training in the use of 
physical restraint for 10 or

IS minutes so each can  restraints, when they use restraints and why, 
really understand what it is  how they felt about restraint use, and how 
like.  they thought restraint elimination would 
affect their jobs. After reading their 
Invite staff from homes that  responses, she was better equipped to address 
have already reduced  their concerns and restraint practices 
restraints to give a  individually. 
presentation on how 
restraint reduction has 
worked for them, or arrange visits to those homes. Residents of nursing homes 
pose similar challenges. Seeing or hearing about a peer s experiences 
demonstrates that restraint reduction is possible. And such objections as "but 
you don  residents are like" are less likely to be made. 
t understand what  our  Involve everyone in the home 
because each has a role to play.  A director of nursing led her home 
As restraints are reduced restraint reduction efforts alone. When 
, it 
becomes vital that everyone  the home became restraint-free, she was 
from the housekeepers to the  recruited by another home to reduce its 
kitchen staff and receptionists  restraints. After she was gone, the home 
knows what to do if someone is  began using restraints again. Without 
wandering toward an exit or  commitment from others, the home was 
sliding down in a chair. And  unable to maintain its 
restraint-free care. 
don t be discouraged if some 
people are reluctant to try 
restraint reduction. Sometimes it takes their seeing actual progress before they 
really believe it can work. 
Recognize up front that reducing restraints takes time.  a big change for 
It  is 
many homes and requires a new way of approaching old problems. Don t delay 
starting because you re concerned that something might go wrong--something 
probably will, but it need not be traumatic, and in fact, could be a learning 
experience.  Our home operates on a tight budget. How can we reduce restraints without spending 
a lot of money? 
None of the homes we visited identified costs as a barrier to reducing restraints. 
These homes had no extra funds, such as a grant, to reduce restraints. 
In general, the homes we  We don t have the staff to do that. ' In 
visited reported using their  some nursing homes that may be true; 
staff more creatively rather  however, it will also be true that the same 
than hiring more staff. Two  staff wil~ in all likelihood, not be able to 
homes, however, did create  care properly for residents  in restraints with 
new positions in conjunction  that Iowa staffing ratio. Understaffed 
with their restraint reduction.
 facilities and facilities that do staff 
One home hired two new  sufficiently to meet residents' needs will find 
certified nursing assistants to  that they are able to use their staff time 
provide one-on-one car;e for  better when they pay more attention to 
formerly restrained residents  individual needs and reduce their use of 
needing extra attention; the  restraints. " (S.  G.  Burger,  Ina"111'oDriate Use of Chemical 
other, a rehabilitation aide  and Physical Restraints. National Citizens ' Coalition for 
to walk residents and help  Nursing Home Refonn  (1989):  30-31. 
them with other activities. 
Most homes identified minor costs for providing training and purchasing 
positioning devices such as cushions. In some cases, family members provided 
reclining or rocking chairs to replace gerichairs, so the ,home incurred no 
expense. 
None of the homes mentioned any renovations related to restraint reduction. 
For example, none moved nurses' stations or added new rooms. Most already 
had alarm systems in place to alert everyone if a resident wandered out the 
door.  What will restraint reduction mean for our malpractice liability risks? 
The homes we visited 
mentioned an increased  The limitations placed on the use of 
awareness of liability risks  physical restraints in the Omnibus 
but no increased costs. In  (OBRA) and the 
Reconciliation Act of  1987 
fact, one home shopped 
guidelines interpreting those limitations are

around and found a carrier  finally putting to rest the myth that restraints 
that offered a less expensive  must be used in order to avoid legal liability. 
policy. .  In fact, court decisions never supported that 
myth, even through all the years when the 
use of restraints had become so widespread 
that their application could be presented as a 
part of '
reasonable care' for the protection of 
patients. " (A R Hun~ "Dispelling the Liability Myth," 
Untie the Elderlv  no.  (April  1991): 1) 
Document your residents  One nurse told us how she documented a 
consent to have their  confused woman s consent to have her 
restraints removed.  restraint removed even though this woman 
was unable to speak, read, or write. The 
woman shook her fist angrily and stomped 
her feet at anyone who attempted to apply a 
restraint. Although she was unable to 
express it in words, this woman clearly 
communicated her desire to be free from 
restraints. The nurse described her gestures 
in the record to document consent. 
Document carefully every aspect of your restraint reduction efforts in each 
resident  results of any restraint alternatives you have 
s care plan. Include the 
tried, goals for the resident, and how the resident will be monitored. In the 
event of a lawsuit, establishing that due care was taken to protect that 
individual from harm becomes vita1.I 
I S. G. Burger Inappropriate Use of Chemical and Physical Restraints  National 
Citizens' Coalition for Nursing Home Reform (1989): 8.  REDUCING RESTRAINTS

How can we get started reducing restraints? 
Assess the condition of all 
restrained residents before you  One home restrained a gentleman 
get started. Know whether they  because he fell repeatedly. In reviewing 
suffer from low blood pressure  his complete medical history, staff 
when changing position from lying  discovered he suffered low blood 
to sitting or sitting to standing,  pressure--which made him dizzy and 
whether they suffer from low  apt to fall--because the dose of his 
blood sugar between meals, what  blood pressure medicine was too high. 
nonpsychoactive medications they  By checking his blood pressure every 
take, and whether they cause  day, and administering the medicine 
sleepiness or other side effects.  only when indicated, this home reduced 
These conditions may increase the  the dose by two-thirds. Now he is 
risk of falls and need to be  unrestrained, and walks around safely. 
addressed before removing
restraints. 
Review the restraint use among your residents. Find out who is 
using physical 
restraints or psychoactive drugs, which type of restraint or drug, how often it is 
used, and why it is used. 
Using the information from your review, categorize the physically restrained 
residents according to some plan. For example, categorize them according to 
why they are restrained (wandering; leaning in chairs; unknoWn) or how often 
they are restrained (never, but has a restraint order; rarely; regularly; always). 
Involve your residents  The administrators or medical directors 
physicians and/or your  usually wrote letters or made calls to ensure 
consultant pharmacist in  their residents ' physicians knew about the 
assessing the proper use  homes ' new policies related to OBRA. 
psychoactive drugs. The  Despite their efforts, not all physicians 
pharmacist can help you  cooperated. Each home told us that at least 
determine whether the use  one physician was reluctant to reduce 
of these drugs is proper  that used the 
psychoactive drugs. Homes 
under OBRA and can  same consultant pharmacist each month 
recommend that the  noted that, over time, the physicians and 
physicians reduce doses or  pharmacists built a professional relationship 
change drugs. Consider  that helped those homes reduce the use of 
designing assessment forms  psychoactive drugs. 
to trigger questions about 
particular diagnoses that 
need to be present if certain 
drugs are used.  Begin reducing psychoactive drugs before physical restraints for those residents 
who are restrained both physically and with drugs. Reducing the drugs first can 
increase alertness, thereby decreasing the likelihood of falls after physical 
restraints are removed. 
Nursing homes are finding creative solutions 
to replace restraints. At one home, a 
confused woman had been restrained in a 
chair with a vest because she liked to lean 
First reduce physical  over and play with her toes, and often ended 
restraints for those residents  up on the floor. By simply 
giving her a large 
who you think will fare best.  stuffed animal instead of strapping her in a 
Your groups of why or when  chair, she forgot about her toes and played 
residents are restrained can  with the animal. At another home, staff had 
help you decide where to  restrained a confused blind woman in a 
start. This way you can  gerichair. Knowing she was Catholic, they 
build experience, confidence  gave her rosary beads when they moved her 
and momentum for the  from the gerichair. She remained occupied, 
tougher cases later on.  content, and safe without the restraint. 
Limit reduction to a few residents per week per unit to keep the process 
manageable. If all restraints are removed at once, everyone in the home may 
feel overwhelmed, and the risks for problems such as falls might increase.  Everyone s biggest concern is safety. Once we remove restraints, how do we prevent 
our residents from falling, becoming 
agitated, or wandering? 
Monitor carefully those 
residents whose restraints  To enhance the monitoring of newly released 
you eliminate--make sure  residents, one home made sure that small 
they are in view of the  handbells were within reach when residents 
nurses' station.  were out of bed and away from their call 
bells or out of sight of the nurses' station. 
They asked the residents to ring the bell 
before they tried to get up unassisted, and 
staff--still afraid of falls--made sure they 
answered those bells quickly. 
Strengthen the residents so their risk of falls will decrease. After a period 
limited mobility due to restraints, they need to regain their lost muscle tone. 
Some homes we visited had  At one home, the staff had a problem with a 
an initial. increase in falls  woman wandering into the nurses ' station 
after reducing restraints, but  where she maneuvered among. the desks and 
no more serious injuries.  cabinets by reaching for chairs on wheels 
Others had no increase in  keep her balance. This led to a few falls. 
falls at all. In fact, some  Rather than replacing the chairs or 
nurses and nursing assistants  restraining the woman, the charge nurse 
were surprised that many  asked a blind woman who enjoyed 
residents stayed seated 
crocheting to crochet a long strand in a

without a restraint.  bright color. The charge nurse then hung the 
crocheted strand across the entrance to the 
nurses ' station. The wanderer no longer 
entered that hazardous area
, but was free to 
wander safely in the halls.  Analyze the fall and incident data  One home analyzed its incident reports 
and use it to prevent further  and found that most incidents--falls 
incidents. For example, is there a  and episodes of wandering--were 
pattern to someone s wandering?  occurring in the lobby during shift 
Do most falls occur at a certain  changes. The home changed this 
time or in a certain place? Is a  pattern by simply assigning a nursing

piece of furniture tipping too  assistant to the lobby area during shift 
easily?  changes. 
Log all agitated behaviors  At one home, the consultant pharmacist 
using precise language. Note  inadequate 
expressed frustration at the 
what might have caused the  documentation of agitated behavior. 
behavior, and what worked  Because agitation can manifest itself in 
to resolve it. If you can find  many ways-.biting, yelling, wandering, head 
too much noise  banging--how could she know whether the 
the cause--
too. cold, loneliness, hunger- particular agitation documented was caused 
you can avoid the behavior  by an improper drug or dose, or by some 
by addressing the cause  other incident? But if the nurse or aide 
without resorting to  documents the specific behavior, like spitting, 
restraints. For example  it helps the pharmacist make the proper 
make sure a tray of late- recommendations in the drug regimen 
night snacks is available, and  reviews. 
a sweater or blanket is 
within reach.  How will restraint reduction affect our activities program? 
Most of the homes we 
visited expanded their  Many of the homes we visited have increased 
activities while reducing  the use of music in their activities. Some 
restraints, particularly  provide headphones with soothing or familiar 
activities for confused  music during late afternoon. Others use 
residents. They even used  music in midmorning programs with the 
simple tasks, such as folding  more confused residents, and encourage 
towels or sorting mail, to  clapping, foot tapping, singing, and dancing. 
engage a confused resident. 
Many also noted that the 
nursing assistants were providing more one-on-one activities, such as puzzles 
games, letter writing, or simply visiting, for those residents less interested in or 
suited to group activities. 
Become familiar with your residents' social histories , and use that information 
to develop activities tht1y will relate to and enjoy. For example, if someone 
worked at a newspaper, perhaps he or she would enjoy starting a newsletter for 
the home with some other residents. 
Develop a mobility program to  One respondent assured us that any 
strengthen residents. Now that  home--even one without much space 
your nursing assistants are free  for activities--can implement an 
from tying and untying restraints  inexpensive mobility program by 
they can devote more time to  purchasing overhead pulleys, pedals for 
walking residents.  chairs, and games like plastic 
horseshoes, bowling sets, and Velcro 
dart sets. Mobility programs not only 
strengthen residents and improve their 
breathing, but also provide another 
activity for them to enjoy. 
Develop more activities for those periods when falls, agitation, or wandering 
increases. Staff at homes we visited said that late afternoon activities helped 
reduce agitation.  Once we have tried letters, phone calls, and personal meetings, what do we do if a 
restrained? 
family member still wants to keep a loved one 
Present a list of the risks to residents' well-being with and without restraints. 
The visual impact of the lopsided list weighs heavily in favor of ,restraint 
removal. Some of the homes we visited include such a list in the consent forms 
that families sign.

RISKS  RISKS 
WITH  WITHOUT 
RESTRAINTS  RESTRAINTS 
Falls, Falls 
Strangulation, Loss
of Muscle Tone, Pressure
Sores, Decreased Mobility,

Depression, Agitation, 
Reduced ,Bone Mass 
Stiffness, Frustration

Loss of Dignity,

Incontinence, Constipation

Contact your ombudsman. Maybe the family simply needs to hear from a 
knowledgeable third party that removing restraints is okay. 
Try the same approach you used with those in the nursing home: stress to the 
family that times have changed, and removing restraints will improve the quality 
of their loved one s life. Invite family members to try on a restraint for IO or 
IS minutes. 
Document the residents' own preferences regarding restraints and share these 
with families. 
One woman told us about her grandmother, who was discharged from the hospital 
to the nursing home. While hospitalized her personality changed completely; she had 
and restrained physically. The nursing home weaned her from the 
been given H aldol 
reports that her grandmother is back to her 
Haldol, and the granddaughter happily 
walking so much. 
by 
former self and is wearing out her tennis shoes 
 MAINTAINING A
RESTRAINT- FREE HOME
Typically, the night shift has fewer staff than other shifts. How do we make sure that 
those on the night shifts leave restraints off? 
Make sure that everyone  At one home, the evening shift staff missed 
out on some inservice presentations about 
from the night shift is 
included in training related  restraint reduction. Because most falls at 
to the home s restraint 
that home occurred between  and  8 P. 
reduction.  the evening staff was especially reluctant to 
reduce restraints, so their need for training 
was great. 
Establish an on-call system so that whenever someone wants to use a restraint 
someone from the leadership team is called first. 
Stress the importance of  certified nursing assistant from a night 
adapting to the needs and  shift told us she wished she knew more 
schedules of the residents.  about drugs and their side effects, because 
This may be especially  less apt to ask the nurses to get 
she might  be 
important for those working  a drug order if she really understood them. 
the night shift, who may be 
used to seeing everyone in 
bed and quiet. Once restraints are removed, interaction among residents and 
the night shift may increase because residents may want to get up and have a 
snack, or watch late-night television.  Once we ve made progress, how do we maintain our momentum? 
Throwaway your restraining devices to prevent restraint habits from 
resurfacing. 
Reassure everyone that falls have not increased by sharing fall data with them 
and provide a forum for everyone to share their concerns and success stories 
with one another. 
the home

One  way  to keep everyone  in 
and ensure
involved  in  restraint reduction 
that all residents are routinely assessed  is 
start a "Room of the Day" program. Each

Encourage everyone to' 
day,  one resident room  is  featured, and every

question any restraints and  the home must visit there.
department  in 
to make sure other 
Maintenance can check that all equipment 

nonrestraining approaches  functioning, and that handrails are the right 
are tried routinely.  height and chairs won t tip easily. The 
bud 
kitchen can bring a favorite snack or a 
the therapists can 
vase with flowers.  And 
conduct an assessment. By rotating the 
the 
rooms featured each  day,  everyone  in 
home  is  involved and every resident 
routinely assessed.

Reinforce your restraint reduction through inservice training. Offer training on 
behavioral approaches to agitation, the side effects of psychoactive drugs 
managing wandering, communicating with residents who suffer Alzheimer 
disease or are otherwise confused, body positioning and range of motion, and 
promoting resident independence.  &: 
Take a look at your admission forms. 
Do they include a box to check for a 
Implement a no-restraints  restraint as needed for safety? If they 
admission policy, and be sure  do, revise those forms so it won t be so 
your residents' physicians and 
easy to order restraints.  (1.  Rader,  Ma1!ic. 
hospital discharge planners know  Mirth: The Jovful Road to 
Mystery. Modification. 
about it. Include the policy in  Restrain/-Free Care. Benedictine Institute for Long 
your pamphlets for families.  Tenn Care  (1991): 5) 
One home was part of a small 
chain in which the 
Tout your home s success at reducing  administrators and nursing 
restraints, and recruit staff interested in  directors from each home met 
working in a restraint-free environment.  regularly. Shortly after the 
nursing home reforms became 
, a local news 
effective
program featured one of the 
chain s homes because of its 
restraint-free care. That 
publicity lit a fire among the 
other homes to follow suit.  , "

CONCLUSION

In this guide, we focused on one aspect, albeit one very important aspect, of a 
nursing home s responsibilities. Nursing home owners, boards, administrators, and 
staff face many complexities in running homes in a manner that is both cost-effective 
and conducive to high-quality care. While we have not addressed these other 
complexities in this guide, we have sought to provide lessons that are consistent with 
them and that come from the homes' own experiences--not from a vision. of what 
could be in an ideal world. Thus, the significance of the lessons we present is in their 
origin. And each has  for 
worked in the homes we visited. Readers will have to decide 
themselves how well they can work in their own homes. 
We recognize that the lessons we present are only a beginning, providing a general 
sense of direction rather than a blueprint to success. Further experience almost 
certainly will result in many more lessons. The process of removing restraints and 
maintaining a restraint-free home is an ongoing one that calls for continuous learning. 
It can be frustrating, but as the director of a State nursing home association indicates 
it can also be extremely gratifying: 
Our facilities report that there has not been an increase in severity or frequency 
of falls or incidents; that there has been a profound improvement in the quality 
of life for these residents; that mobility programs have been instituted which 
morale of staff has increased to 
served to increase physical functioning; that the 
a significant degree; and that families visit their relatives in the nursing home 
more often. 
2 Vivienne Wisdom
, Executive Director, New Hampshire Health Care 
Association  Nursing Home Accord Stirs Confusion among States  Los 
" quoted in the 
Angeles Times March I8, I991: AI.  APPENDIX A
Methodology 
We conducted case studies at seven nursing homes to reach an in-depth 
understanding of lessons nursing homes had learned by reducing physical and chemical 
restraints. We selected homes by randomly picking a sample of 96 homes from the 
HCF A Medicare-Medicaid Automated Certification System (MMACS) that met our 
criteria. Our criteria included: (I) reduction in the use of physical restraints and 
psychoactive drugs between the two most recent certification 
surveys; (2) location in 
Massachusetts, New Hampshire, New York, or Ohio for ease of travel; (3) bedsize 
between 51 and ISO, and; (4) portion of residents receiving Medicaid or Medicare 
meets or exceeds 50 percent. 
We further narrowed our sample by conducting a screening interview with the 
homes' administrator or director of nursing. During that interview we verified the 
information from MMACS and asked some questions about their restraint reduction 
efforts, auspices, continuity in leadership positions throughout their restraint reduction 
efforts, and whether they had received any special funding to reduce restraints. We 
excluded homes that either had turnover in leadership positions while reducing 
restraints or had received special funding, such as a grant, to reduce restraints. Based 
on the information from MMACS and the screening interview, we selected seven 
homes in three States which we believe reflect typical experiences in reducing 
restraints (see appendix B). The table below highlights some of their characteristics. 
# of 
Home  # Beds  Residents  Medicaid  Auspices  Location 
Nonprofit Independent  Rural 
For Profit Chain  Urban 
115  106  Nonprofit Independent  Rural 
114  108  For Profit Chain  Urban 
For Profit Independent  Rural 
130  126  Nonprofit County  Rural 
100  For Profit Chain  Urban 
We visited each home for one or two days and discussed the restraint reduction 
process with administrators, nursing directors, medical directors, consultant 
pharmacists, physical and occupational therapists, activity directors, social workers, and 
training coordinators. We also spoke with staff nurses and certified nursing assistants 
A - from different shifts to get their perspectives. We used discussion guides with both 
closed- and open-ended questions and collected and reviewed any written policies 
related to restraints. In some instances, we discussed the home s restraint reduction 
with residents' family members by telephone. 
Prior to visiting these seven homes, we visited six homes during our background 
research. Three of these homes are well known for their restraint-free care. During 
these visits, we tested our protocols and discussion guides. 
Although the case studies constituted our primary source of information on how to 
reduce restraints, we conducted telephone interviews with administrators and nursing 
directors at homes in Florida, Michigan, Oregon, and Vermont. We also talked with 
representatives of the following national and State groups: the National Citizens 
Coalition for Nursing Home Reform, American Health Care Association, American 
Association of Homes for the Aged, American Medical Directors' Association 
American Occupational Therapists' Association, American Society of Consultant 
Pharmacists, New Hampshire Health Care Association, and Kendal Corporation. 
Finally, we spoke with an independent consultant and staff at HCF A, a State survey 
agency, and an ombudsman program. Many of these people provided the written 
materials that we reviewed for this report (see appendix C). 
A - APPENDIX 
Homes Selected for Site Visits 
Massachusetts 
Baldwinville Nursing Home 
Hospital Road 
Baldwinville, MA 01436 
Willow Manor Nursing Home 
30 Princeton Boulevard 
Lowell, MA 01851 
New Hampshire 
Exeter Healthcare 
131 Court Street 
Exeter, NH 03833 
Maple Leaf Health Care Center 
198 Pearl Street 
Manchester, NH 03104 
Ohio 
Arbors at Waterville 
555 Anthony Wayne Trail 
Waterville, OH 43566 
Blakely Care Center 
600 Sterling Drive 
North Baltimore, OH 45872 
Countryside Continuing Care Center 
1865 Countryside Drive 
Fremont, OH 43420 
B - I APPENDIX C

Bibliography 
Many of the people we interviewed shared publications with us, which we list 
below. This list does not represent everything that has been published about restraint 
reduction, but many of these publications offer 
extensive bibliographies. 
S. G. Burger  Inappropriate Use of Chemical and Physical Restraints  National Citizens 
Coalition for Nursing Home Reform, I 989. 
M. Downs  Eliminating Restraints Resource Manual: A Guide for Nursing Home Staff, 
The Vermont Free-To-Be Project, 1990. 
Hospital Association of New York State  Restraints and the Frail Elderly Patient: 
Practical Considerations for Hospitals and Nursing Homes  I 990. 
Massachusetts Executive Office of Elder Affairs A Practical Guide to Reducing the Use 
of Restraints in Nursing Homes  1990. 
National Citizens' Coalition for Nursing Home Reform  Nursing Home Reform Law: 
The Basics  1991. 
J. Rader Magic, Mystery, Modification  Mirth: The Joyful Road to Restraint-Free 
Care  Benedictine Institute for Long Term Care, 1991. 
C - I