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Liability Landscape

February 1, 2005
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Do You Have the "Right" to Use a Chemical Restraint? by Linda Williams, RN
LIABILITY landscape

Do you have the 'right' to use a chemical restraint? The medical necessity for the use of any form of restraint must be clear and documented in writing before it is used. Therefore, no physical or chemical restraint should ever be utilized for any resident until:
  • a thorough assessment of all the factors that may be the cause of behaviors (necessitating the restraint) have been completed;
  • alternatives have been tried and documented, and have failed;
  • informed consent from the resident and/or responsible party has been obtained; and
  • the physician has given the appropriate orders.
If a physical restraint is utilized in an emergency situation, the facility must obtain orders and a written consent within 12 or 24 hours, depending on state regulations.

The term "informed consent" means the decision maker, usually the durable power of attorney (DPOA) for healthcare decisions, must be given information about the risks, benefits, and adverse effects of the use of the proposed restraint. Once consent is obtained, the facility is responsible for an ongoing assessment of the need for the restraint and assurance that the resident is not declining as a result. The DPOA should be kept informed of this process and can withdraw his or her consent for the restraint at any time. However, discontinuation of restraint usage should be done only after weighing the facts and conferring with fa-cility staff and the attending physician.

By missing any of these details, a nursing facility can find itself in regulatory and/or legal hot water. The following case study is an example of how the staff at one facility thought they had done everything right, but wound up paying a price for missing some important follow-up interventions. Please be aware of the circumstances surrounding this case, and make changes as appropriate at your facility.

The Situation
A resident with a history of dementia and long-standing alcohol abuse was admitted to a residential care facility. Soon after, she began to exhibit psychotic behavior in which her ability to think, respond emotionally, remember, communicate, interpret reality, and behave appropriately was significantly impaired, affecting her daily functions. The woman was seen by her physician and a prescription for risperidone (Risperdal, Janssen Phameceutica Products, LP), an antipsychotic medication, was ordered at 0.5 mg twice a day.

Within two months of starting the risperidone therapy, the woman became lethargic, had involuntary facial and arm movements, and difficulty ambulating. The staff at the residential care facility notified her physician, who then decreased the risperidone dosage by half. Although the lower dosage seemed to help the woman, her daughter requested the medication be discontinued anyway because of the possibility of more adverse effects. The woman had taken risperidone for only six months.

The woman stayed at the residential care facility for another year and then was transferred to the skilled nursing unit within the same complex so she could receive more assistance with her daily cares. Another year passed, and the woman's behaviors began to escalate again, to the extent that she now would hit, kick, pinch, and make verbal threats to staff when they tried to assist her. For several months, staff members attempted various interventions to redirect her behavior but were unsuccessful. Finally during a care conference, the woman's physician again ordered risperidone 0.5 mg be given to her daily. The staff notified the resident's daughter via a phone message but did not obtain her written consent for the risperidone therapy.

Within a week of beginning the medication again, the resident became lethargic to the point that her physician again decreased her dosage by half. By the sixth day of lethargy, the resident began to lose weight from not eating, so a supplement was ordered to sustain her nutritional status. Despite these interventions, the resident continued to be lethargic and refused to eat adequately. The nurses notified the physician several times about the situation until a physician assistant (PA) visited her, almost two weeks after the risperidone therapy began. The PA discontinued the risperidone and noted the woman's increased lethargy. However, the PA neglected to address her nutrition or hydration status. The resident's health continued to decline for the next two days until a nurse notified the physician, who contacted the resident's daughter, and both agreed to send the resident to the hospital.

At the hospital, the resident was diagnosed with severe hypernatremic dehydration and acute renal failure. The resident was given intravenous fluids and slowly improved; however, her renal failure continued. After a month, the resident's hydration status became stable enough for her to be transferred from the hospital to a different skilled nursing facility, per her daughter's request. Unfortunately, the resident remained lethargic and resisted attempts by staff to feed and assist her. She died a month later of renal failure.

The resident's daughter believed that her mother's death was a direct result of the risperidone therapy. The daughter denied giving the staff permission for the drug to be given to her mother at the first skilled nursing facility because of the ill experience she had while at the residential care facility. In fact, she insisted that she clearly told the staff not to give the medication. The daughter hired an attorney to file a wrongful death suit against the first skilled nursing facility.