The length of time a physical restraint is used on aged care residents is based on the judgement of nurses, the aged care royal commission has heard this week.
The Royal Commission into Aged Care Quality and Safety investigated the use of restraints on the second day of the Sydney hearing on Tuesday through a case study of 72-year-old Terance Reeves who was a respite care resident at Garden View Aged Care in Merrylands in western Sydney.
Three of Mr Reeves’ family members, two of his general practitioners and a registered nurse and the director of nursing from the facility gave evidence at the hearing.
After being admitted to the facility in May 2018, Mr Reeves, who is living with dementia, was physically restrained using a lap belt for up to 14 hours a day during his nine-week stay. At the time of admission he was able to toilet himself and walk without assistance, the inquiry heard.
Natalie Smith, daughter of Mr Reeves told the inquiry she was advised that physical restraint restraint would only be used in the interest of her father’s safety to secure him for short periods of time of up to two hours.
“It was only as an absolute last resort, that during a shift change or a medication round there might be limited staff to be able to keep an eye on my dad who frequently wandered around,” Ms Smith said.
However, upon visits to the facility, family members told the inquiry they often found Mr Reeves sitting on a chair in a lap belt restraint with his head on his chest, drooling and drowsy.
Michelle McCulla, Mr Reeves’ other daughter, told the inquiry he was found in restraints on 30 occasions by family members visiting her father.
“Every single time I visited, he was in a restraint except for one day when he was completely unconscious in a bed,” Ms McCulla said.
Ms McCulla also told the royal commission that she suspected her father had been given the antipsychotic medication Risperidone without the consent of the family.
“I suspected that he had been given something as … he had his head drooped, he was drooling, [and] he could no longer focus on us,” Ms McCulla said.
General practitioner Dr Miles Burkitt said he prescribed Mr Reeves Risperidone as he was aware he had previously been given the antipsychotic medication at home and interpreted this as consent.
When Mr Reeves left Garden View Aged Care, he was incontinent, had lost a significant amount of weight and required assistance walking, Ms McCulla said.
Relying on nurses’ judgements
Dr Burkitt’s locum Dr Kenneth Wong conducted a medical review of Mr Reeves upon his admission to the facility.
“I advised the nursing staff that considering Mr Reeves was at risk of falling if he continued to wander around the nursing home, they could use a belt restraint if they were unable to moderate that behaviour by other means,” Dr Wong said in his witness statement.
He told the inquiry on Tuesday there is no time limits on how long belt restraints can be used.
“I depend on the nurses’ judgement,” Dr Wong said.
Garden View Aged Care director of nursing Kee Ling Lau said the length of time Mr Reeves spent restrained was not justified, however the amount of time restraints were used depended on individual circumstances.
“That would be no set up limit because every individual case is different,” Ms Lau said.
She said Mr Reeves was restrained after “a lot of one-to-one care” was provided to him.
Ms Lau said the commonwealth aged care subsidy was insufficient to provide round-the-clock one-to-one care for its 72 residents.
“Garden View always has higher ratios of staffing, but unfortunately it never can afford in any aged care home one to one. There are many occasions where they need one to one [care] and one-to-one staff is given,” Ms Lau said.
Providing one-to-one care is not affordable for more than four-and-a-half hours a day, Ms Lau said.
“We have a baseline and we can increase a little bit but not to the extent [of] 24 hours,” she said.
On the eve of the Sydney hearing, the royal commission released a research paper exploring the use of physical and pharmacological interventions in aged care.
Restrictive practices in residential aged care in Australia notes aged care providers should trial non-pharmacological interventions before administering psychotropic medications such as Risperidone to manage challenging behaviours.
When a psychotropic medication is applied, it is recommended that social interaction interventions be co-administered to mitigate potential negative effects, the report found.
Access this and the royal commission’s other background papers here.
The hearing continues next week.
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