Bedrails continue to be a hot issue

This article submitted by Michael Jacobson on 2/2/99.

The use of bed rails continues to be a hot issue in long-term care facilities, and two weeks ago the debate shifted to the Minnesota Legislature, where the Health and Human Services committee held a hearing on a bill proposed by Rep. Fran Bradley (R-Rochester).

Bradleyís bill, House File 40, would give families the authority to choose bed rails and other restraints.

Currently, bed rails can only be used to treat a particular symptom and only with a physicianís order. Each patient must be assessed individually, and a file must be maintained documenting the reasoning behind using either a bed rail or a side rail.

The use of restraints was once common practice in long-term care facilities. According to a Minnesota Department of Health brochure, prior to 1990 between 30 and 40 percent of all patients were restrained either in bed or in wheelchairs. Currently, the national average is 16 percent. Still, restraints are more common here than in Europe, where restraint use is less than five percent.

A year ago, Minnesotaís rate was at 20 percent.

The storm started last April when state inspection teams started to take a closer look at bed-rail use during their survey trips. All sides were shocked with the results.

ďWe were totally blindsided,Ē Darrell Shreve, director of research and regulation for the Minnesota Health and Housing Alliance (MHHA), an industry trade group, told the St. Paul Pioneer Press.

In the previous 30 months, Jim Williams, director of communications at MHHA, said there had been no single finding of ďserious and immediate jeopardyĒ by the state survey team. Since April, it has been used more than 20 times for bed-rail violations.

Fines for serious and immediate jeopardy can range from $3,000 to $10,000 a day until the infractions are corrected. The state handles the survey and recommends sanctions, but fines are levied by the federal Health Care Finance Administration (HCFA). To date, nearly a million dollars in fines have been issued on Minnesota facilities by HCFA.

Other damaging effects of a serious and immediate jeopardy finding, Williams noted were the damage to staff morale and reputation and the loss of training privileges.

ďWe could have potentially done things differently in terms of the sanctions, but residents were at risk and the facilities were very lucky that the residents didnít end up killing themselves,Ē Mike Tripple, assistant director of the Department of Healthís facility and provider compliance division told the Pioneer Press.

Over 100 deaths occur annually in the United States as a result of restraint use, according to a U. S. Food and Drug Ad-ministration estimate. The Department of Health reports four deaths in Minnesota since 1996 due to side rails.

Tripple said many facilities overreacted to the initial fines. Bed rails are not banned, but they can only be used in cases with medical symptoms and with proper documentation.

A total of 104 facilities were given citations for improper bed-rail use in 1998, only 25 percent of all facilities. In just 22 cases were the violations severe enough for a serious and immediate jeopardy ruling.

The Koronis Manor and the Good Samaritan Care Center had only one minor violation each. The manor was cited in September for bed-rail use, but had the violation corrected before the survey team left the building, according to Karen Ampe, director of nursing. The Good Samaritanís only violation, according to director Tom Kooiman, was for failure to have 24-hour registered-nurse staffing, a citation for which they immediately got a waiver.

Facing the public
Local facilities are on the front lines of this issue every day. ďI guess the frustrating part for us as a facility is weíre caught in the middle,Ē said Kooiman. Residents and families might be accustomed to having bed rails, but facilities cannot yield to their wishes unless there is a medical reason.

Kooiman said in some cases residents have used bed rails for 10 years, until they were taken down this year.

Turning down a request for bed rails may be difficult, but Ampe said facilities are obliged to follow the letter of the law, even if they have personal concerns about it, too.

The family can voice their opinions to the residentís assessment team. Instead of using restraints as a blanket approach to curtail falls, this team needs to search for underlying causes and alternative safety measures, like alarms, padded mats on the floor, bed cushions, and lower bed positions.

If a resident falls out of bed at night, the answer might not be to restrain him. Maybe a new medication is causing increased toileting, and the resident needs to get out of bed and will attempt it despite the increased difficulty.

ďIn some situations, the side rails are more dangerous than not having them,Ē explained Ampe. ďSide rails donít always prevent falls. If the resident is going to crawl over the side rail, it makes it one foot farther to fall.Ē

Side rails are medical devices, just like walkers. Residents arenít allowed to use walkers unless they can do so safely, and now a similar decision needs to be made and documented about bed rails. ďYouíve always got to weigh the pros and the cons,Ē said Ampe.

Pending legislation
Thatís exactly what the original bill in the House and Senate wanted. One of its main tenets is a proposal for ďinformed consent,Ē a process where the resident or family--after hearing about the risks and benefits--could choose to use bed rails. ďWe would support that decision being made as close to the resident as possible,Ē said Williams.

Prompted by constituent complaints, Bradley introduced his legislation last week. An identical bill was introduced in the Senate by Senator Don Samuelson (DFL-Brainerd). That bill was scheduled to have a hearing in the Health and Family Security Committee yesterday.

Even if the bills are eventually signed into law, the issue will still be murky. The current policy being enforced by the Health Department is actually based on federal law. Informed consent appears to contradict the federal requirement of using bed rails only for medical symptoms, said Tripple, and as a recourse the federal government could stop its funding for Minnesota survey teams. Up to 29 percent of the funding, roughly $2 million, could be lost, according to Tripple.

Several efforts are being made to coordinate state and federal policy, and hopefully they will have better success than the Health Departmentís recent request to HCFA to reduce some of the fines levied on Minnesota facilities. That request was turned down, leading to another potential legislative effort to reimburse those facilities with state money.

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