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


ESTABliSHING A COMMITMENT TO RESTRAINT REDUCI10N . . . . . . . . . 3


REDU~G RES~ ......................................... 7


MAINTAINING A RESTRAINT-FREE HOME 

CONCI...USION 

APPEND IX A


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 

changed. Just as a physician 

no longer routinely removes 

a child's tonsils, now we 

know that restraints should 

no longer be used routinely 

because their risks-­

incontinence, stiffness, loss 

of bone mass, and 

strangulation, among others-­

outweigh their benefits. 

Stress the residents' quality 

of life: removing restraints 

can make them happier and 

restore their dignity. 

Have everyone try on a 

physical restraint for 10 or


IS minutes so each can 

really understand what it is 

like. 

Invite staff from homes that 

have already reduced 

restraints to give a 

presentation on how 

restraint reduction has 

Both mobility and personal autonomy are 

threatened by the use of involuntary


restraints. No controlled trial has yet 

demonstrated the ability of restraints to 

prevent injury, but a large body of literature 

attests to their adverse effects, rncluding strangulation, increased agitation, and the many complications of immobilization. 


(1. Francis Using Restraints in the Elderly Because of Fear 

of Litigation, New Eneland Journal of Medicine 320, no. 

13 (1989): 870) 

One director of nursing found her staff 

skeptical about removing physical restraints 

safely. She surveyed them confidentially 

using questions from the Kendal 

Corporation " Untie the Elderly" program. 

She asked about their training in the use of 

restraints, when they use restraints and why, 

how they felt about restraint use, and how 

they thought restraint elimination would 

affect their jobs. After reading their 

responses, she was better equipped to address 

their concerns and restraint practices 

individually. 

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 t understand what our residents are like" are less likely to be made. 
Involve everyone in the home 

because each has a role to play. 

As restraints are reduced, it 

becomes vital that everyone 

from the housekeepers to the 

kitchen staff and receptionists 

knows what to do if someone is 

wandering toward an exit or 

sliding down in a chair. And 

don t be discouraged if some 

people are reluctant to try 

A director of nursing led her home 

restraint reduction efforts alone. When 

the home became restraint-free, she was 

recruited by another home to reduce its 

restraints. After she was gone, the home 

began using restraints again. Without 

commitment from others, the home was 

unable to maintain its restraint-free care. 

restraint reduction. Sometimes it takes their seeing actual progress before they 

really believe it can work. 

Recognize up front that reducing restraints takes time. It is a big change for 

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 

visited reported using their 

staff more creatively rather 

than hiring more staff. Two 

homes, however, did create 

new positions in conjunction 

with their restraint reduction.


One home hired two new 

certified nursing assistants to 

provide one-on-one car;e for 

formerly restrained residents 

needing extra attention; the 

other, a rehabilitation aide 

to walk residents and help 

them with other activities. 

We don t have the staff to do that. ' In 

some nursing homes that may be true; 

however, it will also be true that the same 

staff wil~ in all likelihood, not be able to 

care properly for residents in restraints with 

that Iowa staffing ratio. Understaffed 

facilities and facilities that do staff 

sufficiently to meet residents' needs will find 

that they are able to use their staff time 

better when they pay more attention to 

individual needs and reduce their use of 

restraints. " (S. G. Burger, Ina"111'oDriate Use of Chemical 

and Physical Restraints. National Citizens ' Coalition for 

Nursing Home Refonn (1989): 30-31. 

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 

awareness of liability risks 

but no increased costs. In 

fact, one home shopped 

around and found a carrier 

that offered a less expensive 

policy. . 

Document your residents 

consent to have their 

restraints removed. 

The limitations placed on the use of 

physical restraints in the Omnibus 

Reconciliation Act of 1987 (OBRA) and the 

guidelines interpreting those limitations are


finally putting to rest the myth that restraints 

must be used in order to avoid legal liability. 

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) 

One nurse told us how she documented a 

confused woman s consent to have her 

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 s care plan. Include the results of any restraint alternatives you have 

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 

get started. Know whether they 

suffer from low blood pressure 

when changing position from lying 

to sitting or sitting to standing, 

whether they suffer from low 

blood sugar between meals, what 

nonpsychoactive medications they 

take, and whether they cause 

sleepiness or other side effects. 

These conditions may increase the 

risk of falls and need to be 

addressed before removing

restraints. 

One home restrained a gentleman 

because he fell repeatedly. In reviewing 

his complete medical history, staff 

discovered he suffered low blood 

pressure--which made him dizzy and 

apt to fall--because the dose of his 

blood pressure medicine was too high. 

By checking his blood pressure every 

day, and administering the medicine 

only when indicated, this home reduced 

the dose by two-thirds. Now he is 

unrestrained, and walks around safely. 

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 

physicians and/or your 

consultant pharmacist in 

assessing the proper use 

psychoactive drugs. The 

pharmacist can help you 

determine whether the use 

of these drugs is proper 

under OBRA and can 

recommend that the 

physicians reduce doses or 

change drugs. Consider 

designing assessment forms 

to trigger questions about 

particular diagnoses that 

The administrators or medical directors 

usually wrote letters or made calls to ensure 

their residents ' physicians knew about the 

homes ' new policies related to OBRA. 

Despite their efforts, not all physicians 

cooperated. Each home told us that at least 

one physician was reluctant to reduce 

psychoactive drugs. Homes that used the 

same consultant pharmacist each month 

noted that, over time, the physicians and 

pharmacists built a professional relationship 

that helped those homes reduce the use of 

psychoactive drugs. 

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. 

First reduce physical 

restraints for those residents 

who you think will fare best. 

Your groups of why or when 

residents are restrained can 

help you decide where to 

start. This way you can 

build experience, confidence 

and momentum for the 

tougher cases later on. 

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 

over and play with her toes, and often ended 

up on the floor. By simply giving her a large 

stuffed animal instead of strapping her in a 

chair, she forgot about her toes and played 

with the animal. At another home, staff had 

restrained a confused blind woman in a 

gerichair. Knowing she was Catholic, they 

gave her rosary beads when they moved her 

from the gerichair. She remained occupied, 

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 

you eliminate--make sure 

they are in view of the 

nurses' station. 

To enhance the monitoring of newly released 

residents, one home made sure that small 

handbells were within reach when residents 

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 

an initial. increase in falls 

after reducing restraints, but 

no more serious injuries. 

Others had no increase in 

falls at all. In fact, some 

nurses and nursing assistants 

were surprised that many 

residents stayed seated 

without a restraint. 

At one home, the staff had a problem with a 

woman wandering into the nurses ' station 

where she maneuvered among. the desks and 

cabinets by reaching for chairs on wheels 

keep her balance. This led to a few falls. 

Rather than replacing the chairs or 

restraining the woman, the charge nurse 

asked a blind woman who enjoyed 

crocheting to crochet a long strand in a


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 

and use it to prevent further 

incidents. For example, is there a 

pattern to someone s wandering? 

Do most falls occur at a certain 

time or in a certain place? Is a 

piece of furniture tipping too 

easily? 

Log all agitated behaviors 

using precise language. Note 

what might have caused the 

behavior, and what worked 

to resolve it. If you can find 

the cause--too much noise 

too. cold, loneliness, hungeryou can avoid the behavior 

by addressing the cause 

without resorting to 

restraints. For example 

make sure a tray of latenight snacks is available, and 

a sweater or blanket is 

within reach. 

One home analyzed its incident reports 

and found that most incidents--falls 

and episodes of wandering--were 

occurring in the lobby during shift 

changes. The home changed this 

pattern by simply assigning a nursing


assistant to the lobby area during shift 

changes. 

At one home, the consultant pharmacist 

expressed frustration at the inadequate 

documentation of agitated behavior. 

Because agitation can manifest itself in 

many ways-.biting, yelling, wandering, head 

banging--how could she know whether the 

particular agitation documented was caused 

by an improper drug or dose, or by some 

other incident? But if the nurse or aide 

documents the specific behavior, like spitting, 

it helps the pharmacist make the proper 

recommendations in the drug regimen 

reviews. 
How will restraint reduction affect our activities program? 

Most of the homes we 

visited expanded their 

activities while reducing 

restraints, particularly 

activities for confused 

residents. They even used 

simple tasks, such as folding 

towels or sorting mail, to 

engage a confused resident. 

Many also noted that the 

Many of the homes we visited have increased 

the use of music in their activities. Some 

provide headphones with soothing or familiar 

music during late afternoon. Others use 

music in midmorning programs with the 

more confused residents, and encourage 

clapping, foot tapping, singing, and dancing. 

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 

strengthen residents. Now that 

your nursing assistants are free 

from tying and untying restraints 

they can devote more time to 

walking residents. 

One respondent assured us that any 

home--even one without much space 

for activities--can implement an 

inexpensive mobility program by 

purchasing overhead pulleys, pedals for 

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 

family member still wants to keep a loved one restrained? 

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 

WITH 

RESTRAINTS 

Falls,€

Strangulation, Loss€

of Muscle Tone, Pressure€

Sores, Decreased Mobility,


Depression, Agitation, 

Reduced ,Bone Mass 

Stiffness, Frustration


Loss of Dignity,


Incontinence, Constipation


RISKS 

WITHOUT 

RESTRAINTS 

Falls 

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 

been given H aldol and restrained physically. The nursing home weaned her from the 

Haldol, and the granddaughter happily reports that her grandmother is back to her 

former self and is wearing out her tennis shoes 
 by walking so much. 
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 

from the night shift is 

included in training related 

to the home s restraint 

reduction. 

At one home, the evening shift staff missed 

out on some inservice presentations about 

restraint reduction. Because most falls at 

that home occurred between and 8 P. 

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 

adapting to the needs and 

schedules of the residents. 

This may be especially 

important for those working 

the night shift, who may be 

used to seeing everyone in 

certified nursing assistant from a night 

shift told us she wished she knew more 

about drugs and their side effects, because 

she might be less apt to ask the nurses to get 

a drug order if she really understood them. 

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. 

Encourage everyone to' 

question any restraints and 

to make sure other 

nonrestraining approaches 

are tried routinely. 

One way to keep everyone in the home


involved in restraint reduction and ensure€

that all residents are routinely assessed is €

start a "Room of the Day" program. Each


day, one resident room is featured, and every


department in the home must visit there.€

Maintenance can check that all equipment 


functioning, and that handrails are the right 

height and chairs won t tip easily. The 

kitchen can bring a favorite snack or a bud vase with flowers. And the therapists can 

conduct an assessment. By rotating the 

rooms featured each day, everyone in the 

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. 
&: 

Implement a no-restraints 

admission policy, and be sure 

your residents' physicians and 

hospital discharge planners know 

about it. Include the policy in 

your pamphlets for families. 

Take a look at your admission forms. 

Do they include a box to check for a 

restraint as needed for safety? If they 

do, revise those forms so it won t be so 

easy to order restraints. (1. Rader, Ma1!ic. 

Mystery. Modification. Mirth: The Jovful Road to 

Restrain/-Free Care. Benedictine Institute for Long 

Tenn Care (1991): 5) 

Tout your home s success at reducing 

restraints, and recruit staff interested in 

working in a restraint-free environment. 

One home was part of a small 

chain in which the 

administrators and nursing 

directors from each home met 

regularly. Shortly after the 

nursing home reforms became 

effective, a local news 

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 worked in the homes we visited. Readers will have to decide for 

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 

served to increase physical functioning; that the morale of staff has increased to 

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 " quoted in the Los 

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 

115 106 

114 108 

130 126 

100 

Auspices Location 

Nonprofit Independent Rural 

For Profit Chain Urban 

Nonprofit Independent Rural 

For Profit Chain Urban 

For Profit Independent Rural 

Nonprofit County Rural 

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