access to one’s body” (CMS, 2007). The language of “adjacent to” and “cannot remove easily” can certainly raise concerns among facility administrators when extensive supports are added to a wheelchair, despite the documented clinical benefits. It should be noted that nowhere in these regulations is the issue of specific supportive wheelchair components addressed. This leaves an even greater gap between practitioners’ experience of restraints’ hazards and risks and their concrete knowledge Positioning devices misconstrued as restraints A positioning device is designed to maintain alignment with the primary support surfaces (the seat and back); provide stability and postural support; and promote function. A restraint is intended to limit movement to protect the client and/or others. Seating and mobility technologies are often misconstrued as restraints. Tilt-in-space and reclining wheelchairs are sometimes seen as restraints, as a very tilted or reclined position may hinder the client from exiting the wheelchair. Positioning components that are sometimes seen as restraints include primarily anterior supports such as pelvic positioning belts, anterior trunk supports, anterior knee blocks, and forehead straps. Medial knee supports, ankle straps, trays, and arm straps are also frequently seen as limiting client egress from a mobility base – even if that client does not have the motor ability to stand and ambulate. Positioning equipment Clients may need a wheelchair or seating components that are misconstrued as restraints in some “restraint-free” settings. This equipment can be successfully recommended within current regulations. All secondary postural support devices are actually intended to block or limit movement – either movement that is a result of the force of gravity (postural collapse) or active movement (voluntary or involuntary). The use of any secondary postural support device is indicated only when it is necessary to: 1. Minimize the risk of body postures that impair safety or health, such as those that: a. Increase the risk of skin breakdown. b. Increase pain. c. Increase the risk of orthopedic complications, distortion, and contractures. 2. Restrict and stabilize one body area in order to allow or increase functional movement in another body area (Jones, 2018). Clinical indicators for restraint There are situations in which the intentional use of secondary support components as restraints may be clinically indicated for safety reasons, either to minimize the risk of falls or to limit self-abusive behaviors (Pierz, 2013). In this case, the term “restraint” refers to limiting movement but not to 1) minimize the risk of body postures that impair safety or health, 2) restrict and stabilize one body area in order to allow/increase functional movement in another body area, or 3) support or maintain a specific posture or alignment that the individual cannot achieve or maintain on his or her own. The purpose of using a secondary support component intentionally as a restraint is also not for “coercion, discipline, convenience, or retaliation by staff” (U.S. Government Publishing Office, 2016). The goal is to minimize the risk of injury to the individual in the wheelchair and/or others (Figure 71). Per OBRA regulations, use of a “restraint” is acceptable under these circumstances in a long-term care setting. However, the use of any component to intentionally restrain a client should be avoided if possible; alternative options should be explored (e.g., increased supervision, stimulation), and any restraint should be minimized. If a wheelchair or seating component is intentionally used as a restraint, documentation must clearly state why a secondary support is being used as a restraint and that documentation must then be signed by a physician. Note that following these guidelines will also reduce clinician liability.
of the clinical applications of postural supports. As regulations have evolved over the past decade, there has been a shift conceptually from discussion of a particular device (a bedrail, for example) and its intended use to a discussion of the device’s overall effect on the individual. For example, there may be significant functional improvements from the use of a device; however, it may also have the effect of restraining the individual (at times unnecessarily). 3. Support or maintain a specific posture or alignment that the individual cannot achieve or maintain on his or her own but which is necessary to optimize the individual’s health, comfort, or overall functional abilities (Sparacio, 2018). If a postural support device is necessary for a particular individual to meet these indications, its provision is very specific to individual client needs, and a specialty clinical evaluation is necessary. Many secondary postural support devices are misconstrued as restraints, as these components may limit an individual from getting up and out of the mobility base. However, many individuals using seating and mobility equipment are unable to safely rise, stand, and walk away from the mobility base. For those who lack the cognition or judgment to understand or remember this limitation, there is a potential for falls and injuries. Documentation must justify the clinical indicators for each seating component (Babinec et al., 2015). Most regulations focus on the intended use of the component in determining whether it is being used as a restraint. For example, consider the following recommendation: “A pelvic positioning belt is being recommended to maintain a neutral pelvic position which, in turn, will facilitate a more upright trunk and head position.” In this case, the intended use of the pelvic positioning belt is for postural control, rather than restraint. When such a recommendation is questioned, the practitioner should review pertinent definitions, regulations, and policies of his or her specific work setting. Does the facility, for example, fall under OBRA regulations, or does the facility use another set of rules, and are these regulations the most current and have the regulations been modified?
Figure 71: Forearm Strap
Note . From “Arm & Foot Supports,” by Adaptive Engineering Lab (AEL), n.d., retrieved from http://www.aelseating.com/c-5-arm- foot-supports.aspx. © Adaptive Engineering Lab. Reprinted with permission. To be effective in environments where restraint guidelines can be misinterpreted, seating and mobility practitioners must pay particular attention to documenting the clinical indications as well as risks and benefits of each seating intervention provided. Clinicians would be prudent to include exact language from existing regulations that exempt mechanical postural supports from consideration as physical restraints. Finally, it is important to communicate the beneficial effects of postural supports that distinguish them from physical restraints that are used only in the most regulated circumstances. Seating and mobility practitioners should be viewed as a resource, not only supporting the health and well-being of clients but also serving as partners in regulatory compliance.
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Book Code: PTNC1023
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