Residents of nursing homes and other chronic care facilities may be restrained. The following criteria have been proposed for attributing deaths to restraints: no apparent acute illness at the time of death; restraint at the time of death or immediately before; discovery in abnormal restraint position such that the patient would have had great difficulty in self-extrication; and exclusion of postmortem postural changes (92).
Deaths may be unwitnessed (92-95). In a retrospective analysis of physical restraint deaths occurring mostly in nursing homes, victims were found suspended from chairs or beds (92). Detailed analysis of these deaths showed that all were demented, most had impulsive or involuntary movements, and many had recently tried to escape a restraint or been found in an abnormal position while restrained (92). A vest restraint on a seated patient may be improperly positioned initially or subsequently. A bottom strap may be absent. As a result, sliding under the vest occurs with consequent pressure on the neck, leading to asphyxia (Fig. 5; refs. 92,94-96). These patients, because of diminished physical and mental abilities, are unable to extricate themselves (94). A victim's small size is also a contributory factor (92). A wheelchair can flip, entrapping an individual in a vest restraint (see Subheading 3.7. and ref. 97).
Other types of suspension deaths have been described in this setting: neck compression from an electrically raised head of the bed with an improperly positioned
restraint; slippage between the side bar of a bed and mattress with the neck caught on the side bar; and falling out of bed with the electrical cord of a bedside lamp around the neck (see Subheading 3.2. and refs. 48,92,94,98, and 99). Chest compression may play a role in victims found hanging from beds (see Subheading 3.8. and refs. 92,100, and 101).
Resuscitation efforts alter the position of the patient, and eyewitness accounts documented in medical records are important in determining how the individual died (100,101). The possibility of asphyxiation may be not appreciated, and the physicians certifying the death may not intensively investigate a death in a chronic care facility (92). Staff may attempt to conceal an unnatural death by scene alteration or by failing to report the incident because of fear of criminal and civil proceedings (92,96,98).
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