Jan 2, 2019

Are Restraints Abuse?

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The Chronicle Herald reported the tragic abuse suffered by Thelma Irene Lake at Haliburton Place.  Lake was forcibly placed and tied into a geriatric chair with a restraint. The Health Department investigated and confirmed the abuse.  Even though it’s been nearly two years since 91-year-old Thelma Irene Lake died, her daughter Marlene Hill tears up remembering what she calls the abuse her mother suffered.

“Her only crime was she wanted to use the bathroom,” says Marlene Hill.  Her mother had dementia and spent the last seven months of her life in the nursing home. She was still walking but unable to talk or ring the call bell in her room.

One November night in 2016, Thelma Lake tried to get out of bed several times to get to the bathroom. She shared the room with a 43-year-old woman named Terri Dean. Dean told Marlene Hill that she rang her mother’s bell looking for assistance because she was concerned Thelma might fall. The investigation found some documentation that said she was “at risk for falls.”

According to Dean, a nurse and a male continuing care assistant arrived but they did not take Thelma to the toilet. Instead, they forcefully removed her diaper and tied her roughly into a geriatric chair using a “posey” restraint — essentially, a rectangular piece of fabric placed around the waist with strings that are tied to the back of the chair. Dean told the investigator she heard one worker say, “We are not allowed to use this,” and another confirming, “No, we aren’t,” while continuing to tie her roommate.  Thelma was crying and continued to cry after being dragged out of the room in the chair shortly before 1 a.m. Notes from staff indicate the woman spent four hours and 15 minutes in the chair next to the nursing station.

Restraining a resident is a safety measure of last resort in consultation with the resident (if competent), or with the family. The report found no care plan or consent on file for the senior. Restraints are also to be used for the shortest time possible. In this case, they included the posey and a table tray similar to a child’s high chair.

Hill says she was told by a nurse her mother sometimes received an antipsychotic drug called Haldol to settle her. Dizziness can be a side effect and Haldol is not usually recommended for geriatric patients.

Staff admitted they took these actions to protect “the safety” of the resident.

The investigator ordered Haliburton Place to provide education on the use of restraints to the staff involved in the Thelma Lake incident and to “any other staff who require it.” The nursing home was told to train staff on the definition of abuse, signs of abuse, and how to report it.

Meanwhile, on Friday March 3, 2017, she and her sister called the attention of the registered nurse and licensed practical nurse to their mother’s leg, which was red and swollen from the knee down. Hill, who had previously worked as certified nurse assistant, wondered if it was related to cellulitis or shingles. Both were ruled out.

On Sunday afternoon, nursing notes show a licensed practical nurse reported Lake was short of breath. The nursing assessment mentions the red area on the leg had decreased, while swelling remained. By the morning of Monday, March 6, notes indicate Lake was still experiencing shortness of breath and was “clearly not herself.” Two phone calls to the attending physician who worked in the same building went unanswered.  Thelma Lake passed away at noon.

Nurses on the Monday shift told the investigator they never received information from nurses on the Friday shift concerning Thelma’s leg, and if they had, they would have summoned the doctor much sooner. It was determined Lake died as the result of a blood clot.

“My mother was a human being,” says Marlene Hill. “Blood clots are treatable. Just because she was 91 years old doesn’t mean she shouldn’t have got the medical attention the problem deserved. I don’t think anyone would have called the doctor to check on Mom if my sister hadn’t happened to drop in that morning.”



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Article Categories:
Dementia Care · Fall Prevention

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