'Certain patients need it': Is restraint use too limited by law in Pa. nursing homes?

DALLASTOWN — In the three years before his death in 2021, Harold Garretson fell more than 30 times in various central Pennsylvania care facilities.

Angela Perkinson believes many of her father's hospital visits and MRIs were avoidable. She blames much of his suffering on well-intentioned, one-size-fits-all policy prohibiting the use of patient restraints.

"He deserved to be taken care of," said Perkinson, who lives in York County with her husband.

"There's a time and a place for (restraints). Certain patients need it."

Local data: Coroner: Fall-related deaths remain the No. 1 cause of traumatic demises in York County annually

Local statistics, coupled with state and national trends, put the problem into perspective.

In York County, the coroner's most recent annual report showed that fall-related deaths remain the No. 1 cause of traumatic demises each year, rising another 6% from 2022 to 2023. Coroner Pamela L. Gay wrote that leg and hip fractures are common, with some traumatic brain bleeds occurring as well.

"These injuries are often so severe, that an older person often has great difficulty recovering from them, or they develop complications from being less active, such as pneumonia, mobility issues and skin breakdown," Gay said in her report.

Are restraints allowed in nursing homes?

The permissible use of restraints was limited under the Nursing Home Reform Act signed into law in 1987 by President Ronald Reagan.

The nonprofit National Consumer Voice for Quality Long-Term Care characterized the act as a landmark law, heralding it as "the first major revision of the federal standards for nursing home care since the 1965 creation of both Medicare and Medicaid." A lawyer for the organization said the law established rights for elderly patients and baseline care standards amid growing pressure from advocates nationwide.

Eric Heisler, communications director for the Pennsylvania Health Care Association, noted that a 2008 Centers for Medicare & Medicaid Services report showed the daily use of restraints in nursing homes had dropped from 21% to 5% between 1991 and 2007.

"Providers are seeing an increased demand for care, and higher acuity needs," Heisler told the USA TODAY Network. "But they have regulations –– state and federal –– on how that care should be provided, and we are all, collectively, working to find ways to enhance care.

"The evolution of eliminating restraints (straps, bed rails, medications, etc.) is part of the effort of providers and regulators to further enhance care and respect resident dignity."

Pennsylvania Department of Health Press Secretary Mark O'Neill noted that this is addressed under Title 28 of the Pennsylvania Code. This section states that care facilities "shall use the least restrictive method for the least amount of time to safely and adequately respond to individual resident needs in accordance with the resident’s comprehensive assessment and comprehensive care plan."

Specifically, the code requires physical restraints to be removed for at least 10 minutes out of every 2 hours and for a resident's position to be changed at least every 2 hours during normal waking hours.

Perkinson said she requested restraint use for her father in each care facility: hospital, assisted living, skilled care, rehab and eventually hospice. She was told no in each instance, even though her father's combination of dementia and blood pressure problems increased his risk of falling as he aged.

"Somehow these regulations have morphed into 'no restraint for any reason,' the safety of the patient be damned," Perkinson said.

"There may be facilities in this country where innovative approaches to fall prevention are being implemented, but in my family’s experience we did not find such a facility. The available safety procedures are much the same as they have been since 1987, when this supposed 'landmark' Nursing Home Reform Act was passed by Congress."

At one point, Perkinson said, facility staff told her she could hire a third party to individually watch her father around the clock.

According to Perkinson, the estimated cost would have been $150,000 per year in addition to the $144,000 per year already being paid to the skilled care facility.

When restraints are abused

Using restraints has, in some cases, led to allegations of neglect or even abuse.

In 2022, a USA TODAY Network investigation found that at least 50 patients were improperly restrained in New York state between 2015 and 2018. Hospital inspection reports included allegations of men and women being "handcuffed, hit with batons, drugged and left strapped to beds up to 12 hours without regular check-ups and water."

In some of these instances, the patient restraints were used without a licensed health provider's order, which is required by law.

Alarming: Thousands of patients are restrained in hospital ERs and wards with limited oversight

Are care reforms coming?

The push for reform has been an exhausting runaround, Perkinson said. She said she contacted the Pennsylvania Department of Health, which referred her to the York County Agency on Aging, where an ombudsman for the agency referred her to the state Department of Health.

State Rep. Mike Jones (R-York), a member of the state's Aging & Older Adult Services Committee, told her he'd bring up the matter in the Legislature, but she said she never heard back from him, and her attempts to attract the attention of the American Association of Retired Persons and Medicare office were unsuccessful.

When she spoke to someone at the Pennsylvania Office of Attorney General, she said she was informed that this was a job for the Legislature. She added that a private lawyer told her they wouldn't take the case unless her father's injuries created irreparable harm and financial damage.

To Perkinson, none of this is about money. She said her goal is to prevent others from going through what her father endured in the years preceding his death at age 90.

"I'm sure I'm not the only one who's experienced this. It's just wrong," she said.

Perkinson also mailed a letter last year to U.S. Sen. Bob Casey (D-Pa.), chair of the Senate Special Committee on Aging.

Casey said he and fellow committee members contacted CEOs of the three largest operators in the nation — Brookdale, Atria and Sunrise — to learn more about staffing levels and patient-to-caregiver ratios. Committee members cited this as part of a look at whether federal changes are needed to improve conditions.

“You have a set of cascading crises: the staffing problem, the oversight problem, a lack of information the family members need and, at a fundamental level, you have the quality of care problem,” Casey said in a news release.

Additionally, Casey hosted a congressional hearing on problems at assisted living facilities Jan. 25. Perkinson was among those who provided testimony.

“Every Pennsylvanian deserves the care they need to age with dignity,” Casey said in a statement to the USA TODAY Network.

“Right now it’s clear that Americans in assisted living facilities are far from guaranteed to get the care they deserve, with workforce shortages, prohibitive costs, and a general lack of transparency about the adequacy of care plaguing facilities around the country. I’m working to hold accountable the largest corporate owners of assisted living facilities, and to forge a pathway towards making quality care more accessible for aging Americans.”

Federal data mirrors many of the alarming trends in York County and across Pennsylvania.

Falls caused more than 30% of all unintentional injury deaths among older U.S. adults in 1999, according to the Centers for Disease Control and Prevention. They accounted for 58% of these unintentional injury death by 2020.

'One-size-fits-all models create difficulties'

Moving forward, Heisler said he and his organization would support any innovations in care and policy that improve patient safety without stripping them of their dignity.

"We understand the need for the change in the regulation more than 35 years ago. We respect the rights, dignity and safety of the residents we care for," Heisler said.

"We recognize all residents have differing care needs, which is why one-size-fits-all models create difficulties in providing care, but we applaud innovations that have been adopted to support residents without applying measures that have been designated as a form of abuse."

Perkinson said she believes there has to be middle ground between prohibiting restraints and using them abusively. She hopes increased awareness about the statistics illustrating how frequently falls in care facilities are occurring will lead to changes.

"Like any medical condition, the course of treatment should be left to decisions between the doctor, patient and or guardian, not to the bureaucracy of a government agency or the administrators of a local healthcare facility, where financial interests often override decisions on appropriate care," Perkinson said.

Health care: COVID-19 walloped Pa. hospitals with added costs, staffing needs. Here are the numbers.

Bruce Siwy is a reporter for the USA TODAY Network's Pennsylvania state capital bureau. He can be reached at bsiwy@gannett.com or on X at @BruceSiwy.

This article originally appeared on York Daily Record: Are restraints legal in PA nursing homes?