Case # 2: Patient Left Unrestrained, Patient Injured. Nurses Judgment Call.

(SOURCE: http://www.nursefriendly.com)

Summary: The decision to use or not use restraints must be made with caution and good judgment. Their intended purpose must be to protect either the patient or others who may be injured by the patient including the staff caring for the client. The ultimate determination of necessity is left with the physician. Often, the moment to moment necessity is determined by the nurse. In this case a nurse did not feel restraining the patient was necessary. When an injury occurred, the patient sued. The patient was involved in a motor vehicle accident. A head injury was suffered leaving him in a state of confusion and prone to agitation. Following the head injury, the patient was visibly confused and frequently became agitated. During the course of his admission, an order for "soft" wrist restraints was obtained and implemented to protect the patient from injury related to mental status (personality) changes. On the day of the incident, the nurse on duty had assessed the patient. In her professional opinion restraints were not needed. She based this decision on her observation of the patient's mental, physical state and level of consciousness. It is common procedure and protocol in facilities for patients to be released from restraints when the danger of violence is felt to have passed. Later in the shift, the same nurse was helping the patient get up. In the course of this maneuver, the patient fell and claimed that an injury was sustained. A lawsuit would be filed against the facility alleging negligence on the part of the nurse. The patient contended that the removal of the restraints breached standards of care. In the initial trial, the jury was instructed to view the nurse's role as an "error in judgment." Based on this and on testimony on the proper use of restraints, standards of care, the court found for the facility. The patient appealed. Questions to be answered: 1. Was the nurse in error to remove the restraints from a patient when she felt they were no longer needed? 2. Did the removal of the restraints directly contribute to the "injury" that the patient claimed to sustain? 3. Were the standards of care governing restraint use adequately maintained?

REACTION: Before anything else, I think it is only appropriate and necessary that we define what a restraint means. Restraint is a physical force, mechanical devices, chemicals, seclusion, or any other means which unreasonably limits freedom of movement. Commonly, it is used to restrict patients who are acting, or threatening to act, in a violent way towards themselves or others. When an emergency no longer exists, the patient should be released. Thus, staff should release a patient who, upon examination, appears calm. In this specific case, the nurse on duty felt that restraints were not needed after properly assessing the patients mental, physical, and level of consciousness. The nurses professional opinion, however, was immediately questioned after the patient fell and an injury was sustained in the process of ambulation. Now, was the nurse in error to remove the restraints from a patient when she felt they were no longer necessary? The patients arguments aimed to convince the jury that poor judgment was exercised by the nurse. It was also asserted that the removal of the restraints and the ambulation had endangered and caused harm to the patient. But, with the patient assessed to be calm, the purpose of the restraint, which was to restrict the patient who are acting, or threatening to act, in a violent way towards themselves or others, had been clearly achieved. The purpose of the restraints had not been to keep the patient from falling out of bed. Hence, the removal of restraints could not be deemed as negligent. Did the removal of the restraints directly contribute to the "injury" that the patient claimed to sustain? After reading the article, I dont think there is a direct relationship between removing the restraints and the patients fall. In this case, the order was in place to ambulate the patient when he is already in a stable condition and, to the best of the nurses knowledge she saw no reason not to ambulate the patient. The decision to remove the restraints was clearly a nursing decision and the actions of the nurse on duty only exercised reasonable concern for the patients recovery and well-being. Little documented evidence exists that restraints prevent falls and risk of injury from falls and the fact that the patient suffered a fall was completely unforeseeable, however it cannot be attributed to the nurses judgment to remove the restraints. Were the standards of care governing restraint use adequately maintained? After reviewing the facts in this case, I think the standards of care in regarding restraint use were adequately maintained by the nurse. It was stated that during the course of the patients admission, he was visibly confused and became frequently agitated, causing for an order for soft restraints to be obtained and implemented to protect the patient from any bodily harm. But, on the same day of the incident, after carefully observing the patients mental, physical state and level of consciousness, the nurse felt that restraints were not needed. Often, the decision to use or remove restraints lies with the nurse, too. And in this specific case, the nurse who had attempted to carry out the physicians orders not only acted within her scope of practice, but also clearly adhered to standards of care.