On the morning of what would become the last day of her life, Mrs. Jefferson was given care and placed in her wheelchair - with the seat belt fastened – where she would remain for the rest of the day.
She would be found shortly before midnight - on the first rounds carried out by the night shift - sitting on the foot pedals of her wheelchair. Her arms were under the belt and by her side, and the seat belt was caught tightly at her neck.
Her roommate, tucked into and adjacent bed, was oblivious to the long struggle it must have taken Mrs. Jefferson to get into the position where she was found. The door to her room had been closed.
Mrs. Jefferson's cause of death reflected 'accidental asphyxiation due to ligature strangulation'.
No nurse wakes up and heads to work with the intent to cause a catastrophic outcome to someone in their care. But far too often, that is exactly what happens.
This article will focus on the key responsibilities of staff to ensure the safety of residents like Mrs. Jefferson; it will also describe the gaps in care that contributed to her death.
Assessment and re-assessments
Assessment is the root of all nursing actions; it helps to highlight a resident's strengths and weaknesses and provides focus to their plan of care by identifying interventions that will help to maximize the resident's health, safety and well being.
Assessment is focused. For example, the nurse, using tools based on best practice, will initially determine the resident's risk of falling, skin integrity and risk for skin breakdown, pain frequency and severity, as well as key safety requirements, such as the use of a mechanical lifting device. Diagnoses and opinions from other health disciplines will also be incorporated into the assessment. Thereafter, re-assessment occurs on a regular basis.
In Ontario, legislation requires re-assessment within six weeks of admission, quarterly thereafter or when there has been a significant change in health status.
The decision to restrain
In the case of making the decision to determine if restraints are indicated, both the initial assessment and re-assessments should involve the interdisciplinary team, and be triggered as a last resort when all alternatives to restraint use have been thoroughly exhausted.
When a seat belt cannot be undone by the resident or if he/she lacks insight and judgement to understand why it is applied, then this is considered a restraint.
The evidence – or lack thereof
In the case of Mrs. Jefferson, there was no evidence of an initial assessment for the 'need to restrain'. Despite this, the health care record contained two quarterly re-assessments indicating ongoing need for restraint - one which was not dated, and neither of which were signed by the nurse(s) who completed them.
Mrs, Jefferson's overall health status had deteriorated markedly since she was first restrained: her ability to ambulate was difficult if not impossible - even with two staff members. She was also unable to communicate her needs.
None of the recorded falls throughout her stay at Happy Hollow were as a result of attempting to rise from a chair, and four of the six falls had occurred in the presence of others. Indeed, for well over a year prior to her death, there was documentation to indicate that she could not initiate positional transfers on her own, and that she was unable to independently move or change position.
There was no evidence to indicate that, despite the above observations, the continued need for restraint was properly re-evaluated. Just prior to her death, medication that had been prescribed as needed for agitation, had been discontinued due to its non-use. No alternatives to restraints had been implemented and there was no evidence indicating that the health care team had considered all of these factors in determining whether the use of a seat belt was still warranted.
Justifying the decision to restrain
Despite the scores on her Falls Assessment, the types and circumstances of the few fall episodes she experienced in the 18 months prior to her death, did not automatically justify the need for a restraint. Rather the health care team should have considered that Mrs. Jefferson was not changing position on her own, nor was she transferring herself or agitated; thus interventions to reduce the risk of injury should have been identified instead.
A Physician's Order and Consent to Treatment is a fundamental requirement that is inherent in the Health Care Consent Act (1996). Regulations, standards and best practice guidelines around the use of restraining devices are many and have been developed related to the significant risk they present to a person who is restrained.
In 2001, the Province of Ontario enacted the "Patient Restraints Minimization Act" with the purpose of minimizing the use of restraints on patients and to encourage the use of alternative methods whenever possible. Both this legislation and the standards outlined by the Ontario Ministry of Health and Long-term Care (MOHLTC) require consent to treatment obtained from the resident or a Substitute Decision Maker.
The reality of restraint use
At times, the family will insist on restraint use because they perceive that it will keep the resident safe from harm. In reality, the opposite is true; restraints do not eliminate falls; further, they can cause de-conditioning of muscle tone and increased depression and agitation.
Providing health teaching to the family, as well as explaining the risk of applying restraints, is a vital part of making the decision of whether or not to restrain a resident. For Mrs. Jefferson, this did not happen. Her restraint was initiated without her husband's written consent and continued to be used without ongoing consent. As well, there was no evidence of any discussion with the physician, nor was an order for restraint obtained from him. Furthermore there was no evidence for its use outlined in her plan of care.
Responsibility to document
Documentation of the ongoing use of restraints in nursing homes is a responsibility that is shared between registered staff and personal support workers (PSWs) - or unregulated care providers (UCPs). Registered staff are responsible for documenting the interdisciplinary assessment, alternatives to restraints that have been tried, obtaining the consent and physician's order, reviewing and signing the monitoring record to ensure proper completion and the resident's response to restraint, as well as re-evaluation for its ongoing need.
The monitoring record of restrained residents is typically recorded by PSWs on a separate restraint monitoring form. Reflecting the duration of a month, all shifts in a 24-hour period are shown in hourly blocks and identify a code that would be placed in the box to reflect what monitoring activity would have occurred and the resident's response at that time. The form would also include the physician's order, the type of restraint, when it was to be applied and for what reason.
For Mrs. Jefferson, there was no evidence of any restraint monitoring documentation, including hourly checks and her change of position – which should have occurred every two hours – for the duration of the time she had been restrained.
Recording care provision
All long-term care staff have a duty of care to ensure that the needs of residents, especially those related to safety, are met. For PSWs this means providing residents with assistance for all ADLs according to their assessed needs, to conduct rounds at the beginning and the end of their shift, and be able to account for the whereabouts of residents throughout their shift. They are also responsible for documenting the care provided. In long-term care, this is typically completed on a paper or an electronic flow sheet using a "tick", with the PSWs initials signed at the bottom.
Mrs. Jefferson was totally incontinent, had chronic diarrhea and impaired skin. Her plan of care reflected that she was to be checked hourly relative to her cognitive status, that her incontinent products were to be changed frequently and a turning schedule every two to four hours was identified.
On the evening of her death, Mrs. Jefferson's care was signed off by a PSW and included the provision of oral and bedtime care, that she was calm, incontinent, transferred using a lift, and that snacks and fluids were given. The initials of the PSW who provided this care were on the form, but undecipherable. The flow sheet further reflected that no rest period had been provided to her at all that day and her usual bedtime was 6:30 p.m.
Bedtime and other care, as well as provision of a snack, had been checked off as completed; however the fact that Mrs. Jefferson was found non-responsive and fully clothed in her wheelchair was strong evidence suggesting that this care had, in fact, not been provided.
The registered staff administered her bedtime medication at 8 p.m. and would have observed that she was in her room and in her wheelchair.
Someone did provide bedtime care to her roommate and would have been aware that Mrs. Jefferson was uncared for at that time. Finally, someone closed the door as they left, meaning that the fact that she was not yet in bed was not observable to anyone walking down the hallway that evening.
This further meant that, from the time she was first placed in her wheelchair until she was found some 16 hours later, she was not offered any opportunity for a full change of position. The extreme discomfort this must have caused her was, no doubt, a contributing factor to her final attempt to wiggle out of the chair and resulting in her death.
Without a doubt, long-term care staff are challenged to meet complex resident care needs with limited staffing resources. However, complacency with basic nursing care standards, failure to follow policy and procedures, or documenting care 'as given' when it was not, will never be of benefit. As well, "I didn't have time" is not an excuse that will stand up in a court of law.
Lessons to be learned
So what lessons can be learned from this unfortunate and preventable tragedy?
For registered staff, assessment must be thorough and consider all factors that contribute to the outcome. While electronic assessments have helped make documentation more efficient, it has not removed the responsibility to ensure that when re-assessment is being completed, all questions are properly reviewed and answered accurately for that point in time. For homes still using manual tools, the same principles apply, as does the importance of properly dating and signing the form.
Incorporating a variety of perspectives using an interdisciplinary approach will also ensure that the true needs of the resident are identified. Just because a resident may score as a high risk to fall, does not have to result in a decision to restrain. Restraint is not a fall-prevention strategy.
As unregulated care providers, PSWs are not accountable to any licensing body. That does not mean they are exempt from responsibility for the care they provide to the resident and accurately documenting that care.
Registered staff are responsible for "providing the appropriate degree of either direct or indirect supervision, based on the client's condition,... the resources available in the setting and the degree of competence of the UCP".
If assignment challenges had been identified as having negatively impacted the ability of the staff to meet the needs of Mrs. Jefferson, it would have been the responsibility of the registered staff to respond to those challenges.
When looking back or conducting a reflective review of this resident's health care record, it is easy to see how each decision, or lack of one, impacted Mrs. Jefferson's final outcome. Regular auditing, especially for residents at high risk, is a proactive approach that will help to identify processes that require improvement or further education to ensure compliance.
There is no question that Mrs. Jefferson's death was a traumatic experience for the staff of Happy Hollow and, with hindsight, it is easy to identify how approaches to her care should have been done differently. However, it is not enough to wait for a catastrophic outcome to occur.
All care providers have the duty to ensure that they are following the policies, procedures and practice guidelines that will ensure resident safety and reduce the inevitability of litigation that will occur with avoidable, catastrophic outcomes.
NOTE: Names identified with an * asterisk and some details have been changed to protect the privacy of individuals.
Lynda Welch RN
About the Author: Lynda Welch has spent 30 years in management positions in long-term care homes. She is an experienced and respected Legal Nurse Consultant providing opinions in long-term care cases.
Originally Published in Canadian Nursing Home magazine, July 2014, Vol. 25 - No 2 (reprinted with their permission) Lois K. Evans and Valerie T. Cotter, American Journal of Nursing, Avoiding Restraints in Patients with Dementia, March 2008, Vol. 108, No.3, page 42  College of Nurses of Ontario, Practice Guideline, Working with Unregulated Care Providers, 2009; page 15