Why can't nursing homes use restraints?

Oct 28, 2025 3 min read •

senior care Elder Law Residents' Rights

Since the landmark Nursing Home Reform Act of 1987, federal law has significantly restricted the use of restraints in long-term care facilities. This critical legislation was passed to protect resident rights and dignity, shifting care practices away from using physical or chemical restraints for staff convenience or discipline.

Quick Summary

Restraints are heavily restricted in nursing homes by federal law, primarily the Omnibus Budget Reconciliation Act (OBRA) of 1987, because they pose significant physical and psychological dangers to residents. They cannot be used for discipline or convenience, only for specific, documented medical needs as a last resort.

Key Points

Legal Mandate: Federal law, specifically the Omnibus Budget Reconciliation Act of 1987, heavily restricts restraint use in nursing homes, allowing it only for documented medical symptoms and never for staff convenience or discipline.
Significant Health Risks: Restraints increase the risk of serious physical harm, including pressure ulcers, muscle atrophy, and death from falls or strangulation.
Psychological Harm: The use of restraints inflicts severe psychological trauma, leading to anxiety, depression, a loss of dignity, and accelerated cognitive decline, especially in those with dementia.
Ethical Considerations: The practice violates a resident's right to autonomy and self-determination, disrespecting their dignity and leading to potential neglect or abuse claims.
Effective Alternatives Exist: Modern care focuses on person-centered alternatives like environmental modifications, enhanced supervision, and therapeutic activities to address root causes of behavior without relying on restraints.
Informed Consent: Restraints cannot be used without informed consent from the resident or their legal representative, and residents have the right to refuse or revoke consent.

Restraints as Abuse and Neglect

Once a common practice, research demonstrates that physical and chemical restraints can be detrimental to nursing home residents. As a result, unnecessary restraint is now recognized as a form of abuse and neglect. Residents may experience psychological trauma, including depression, anxiety, and a loss of dignity. Physical consequences can include pressure ulcers, muscle atrophy, and an increased risk of injury from falls.

The Legal and Ethical Framework

Federal and state laws, particularly OBRA '87, strictly govern restraint use in nursing homes. This law requires facilities receiving federal funding to protect resident rights, including freedom from unnecessary physical or chemical restraints.

For Medical Symptoms Only: Restraints are only allowed to address documented medical symptoms with a physician's order detailing the reason, duration, and circumstances. They cannot be used for staff convenience or discipline.
Least Restrictive Alternative: Facilities must first try less-restrictive options. Any restraint used must be the least restrictive possible and for the shortest necessary time.
Informed Consent: Residents or their legal representatives must provide informed consent after understanding the risks, benefits, and alternatives. Consent can be withdrawn at any time.

Physical vs. Chemical Restraints

Both physical and chemical restraints are subject to strict regulations.

Physical Restraints: These are methods or devices that limit a resident's movement or access to their body, such as ties, vests, or certain bed rails and lap trays.
Chemical Restraints: This involves using psychopharmacologic drugs for staff convenience or discipline instead of treating a medical condition. Over-sedating a resident with antipsychotics to manage behavior is an example. These medications carry significant risks for older adults with dementia, including increased stroke and death risk.

The Dangers of Restraint Use

Research indicates that restraints often fail to prevent falls and introduce numerous new risks.

Physical Risks

Increased Fall Risk: Restraints can lead to loss of strength and balance, making falls more dangerous.
Injury and Death: Residents are at risk of severe injury or death from issues like strangulation, aspiration, or trying to escape restraints.
Immobility-Related Issues: Lack of movement can cause pressure ulcers, muscle weakness, incontinence, and reduced bone mass.

Psychological Risks

Trauma and Distress: Being restrained is traumatic and can result in emotional distress, anxiety, and PTSD.
Cognitive Decline: Restraints can exacerbate confusion, humiliation, and distress, potentially accelerating cognitive decline, particularly in those with dementia.
Loss of Dignity: The feeling of helplessness significantly impacts a resident's dignity and self-worth.

Alternatives to Restraints

Person-centered care focuses on identifying and addressing the root causes of behavior. Effective alternatives include:

Environmental Modifications: Making the environment safer with measures like removing clutter, adjusting lighting, and using low beds with floor mats to reduce fall risk.
Personalized Interventions: Creating individualized care plans with routines, frequent toileting, and pain management.
Enhanced Supervision: Increasing staff presence and consistent assignments to build trust and better anticipate needs.
Therapeutic Activities: Engaging residents with activities, music, or art to address agitation.
Assistive Devices: Using devices like motion alarms or trapeze bars to support mobility.


Aspect	Restraint-Based Approach	Restraint-Free Approach
Goal	Control resident behavior or manage staff convenience	Understand root causes of behavior and meet individual needs
Focus	Limiting physical movement	Enhancing freedom, dignity, and autonomy
Technique	Physical or chemical devices	Individualized care plans, environmental adjustments, therapeutic activities
Outcomes	Increased risks of injury, psychological distress, and faster decline	Improved resident safety, reduced agitation, and enhanced quality of life
Ethical Basis	Outdated approach based on control and convenience	Modern, person-centered philosophy based on respect and dignity

The Path Forward: Promoting Dignity and Safety

Moving away from restraints represents progress in senior care, prioritizing resident dignity, autonomy, and psychological well-being. By focusing on prevention, a supportive environment, and individualized attention, nursing homes can create safer, more compassionate spaces. Reducing restraint use is vital for improving the quality of life for vulnerable individuals. Resources like the California Advocates for Nursing Home Reform (CANHR) advocate for restraint-free care.

Frequently Asked Questions

Yes, but only under very specific and limited circumstances. Restraints are legally permissible only when medically necessary to treat a resident's specific, documented medical symptoms and only after all less restrictive alternatives have been attempted.

Physical restraints are devices or methods that limit a resident's movement, like vests or bed rails. Chemical restraints are medications, such as antipsychotics, used to control a resident's behavior for staff convenience rather than for a diagnosed medical condition.

Federal guidelines and research show that using restraints for fall prevention is not only ineffective but often increases the risk of more serious injury. Safer alternatives, such as low beds and floor mats, are preferred.

If you suspect restraint misuse, you should first document your concerns and then report the abuse to the appropriate state licensing agency or Long-Term Care Ombudsman Program. Legal action may also be an option.

A resident or their legal representative must provide informed consent for any restraint use. The facility must fully explain the risks, benefits, and alternatives, and consent can be withdrawn at any time.

Effective alternatives include individualized care plans, therapeutic activities, enhancing supervision, providing assistive devices, and modifying the environment to ensure resident safety and comfort.

Restrained residents can suffer from increased agitation, anxiety, depression, and a loss of dignity. The experience can lead to long-term psychological trauma, including PTSD.

The Nursing Home Reform Act of 1987 is the primary federal law prohibiting the unnecessary use of restraints for discipline or convenience. Regulations from the Centers for Medicare and Medicaid Services (CMS) also reinforce these protections.

References

Medical Disclaimer

This content is for informational purposes only and should not replace professional medical advice. Always consult a qualified healthcare provider regarding personal health decisions.