Restraint-Free Care in Nursing Homes

Case Study II:
"Siderail Use - High Risk for Falls"

Mr. Parker is an 86- year old man, admitted to the facility 9 months ago. He has a diagnosis of multiple CVAs, arthritis, and advanced dementia. He has severe contractures of all extremities, is incontinent of bowel and bladder and requires full assistance with all activities of daily living. Mr. Parker strikes staff when personal care is provided, especially at night when the staff attempts to change his brief. He has full -length rails, in the up position when he is in bed, with vinyl pads to prevent injury from contact with the rails. He attempts to leave the bed by “squirming” toward the foot and going out the bottom. As a result, he has been found on the floor next to his bed several times, with skin tears, lacerations, and a fractured humerus resulting. He receives an anti- anxiety medication at bedtime to reduce his “combativeness.”
Mr.Parker’s MDS triggers Behavioral Symptoms, Psychotropic Drug Use and Falls RAPS. When the nurse practitioner assesses him, he attempts to hit her when she attempts to assess his range of motion and degree of contracture. His face is contorted with grimacing and he moans loudly. He clearly experiences pain with movement.

Mr. Parker was assessed to be at risk for falls and injuries related to the following:

1. History of falls/injuries
2. Impaired cognitive status
3. Pain- related to contractures, arthritis, and recent fractured humerus
4. Diagnosis- DJD and contractures
5. Use of anti-anxiety agent
6. Environmental hazards- bed with siderails in high position.


Interdisciplinary recommendations included the following interventions:

    1. Treat pain with Ibuprofen 400 mg. every 6 hours. On-going pain assessment, using a tool for non-verbal residents.
    2. Taper and discontinue anti-anxiety agent.
    3. Replace current bed with adjustable –height electric bed that places him approximately 7 inches above the ground. Mats on each side of the bed. Body pillows for comfort and positioning.
    4. Communicate using eye contact, gentle touch and physical cues.
    5. Provide incontinence care every 2 hours until 11 pm, then at 3 am and 6 am to allow uninterrupted rest. Assess and log incontinence to refine this schedule.
    6. Passive ROM with aromatherapy twice a day.

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Last updated July 25, 2003