Case Study 102

Clinical Research: Patient with Huntington’s Chorea

Mr. R. was a 68 year old gentleman admitted to the Long Term Care (LTC) Facility from his home with a diagnosis of worsening Huntington’s Chorea. The patient had been in the care of his family. To help control the patient’s involuntary writhing and spastic movements, chest and limb restraints had been used on a near continuous basis.   The patient also had several pressure ulcers.

The Director of Nursing was very concerned about the most effective approach to this difficult patient / family situation.  Following the Joint Commission of Accreditation of Healthcare Organization (JCAHO) Standards 1 as well as the Health Care Finance Administration (HFCA) regulations 2 for the “least restrictive device”, many issues were explored. Top consideration was given to choosing the most effective device that would provide comfort, dignity and safety for the patient as well as peace of mind for the family. It was also important that the nursing staff have easy access to provide patient care.

Mr. R.’s family insisted the patient continue in limb and chest restraints, as this was the only approach they knew.  The Director of Nurses knew this was not the only option and discussed the Safe Enclosure with the family.  She explained that the Safe Enclosure could be used over the regular bed frame. This would meet the regulatory requirement of using the “least restrictive device” while providing a safe yet dignified environment for the patient. Also, a pressure relief mattress could be applied that would meet the treatment goals for Mr. R.’s pressure ulcers.  The family consented on behalf of the patient, and the attending physician wrote an order for the Safe Enclosure.

The Safe Enclosure allowed the nursing staff to address the patient’s wounds without restricting access to the patient. A pressure relief mattress was placed within the Safe Enclosure in order to meet the treatment goals for the patient’s pressure ulcers. The Director of Nursing reported “the patient actually cried tears of relief” that he could rest safely without the use of restrictive restraints. The family agreed this was the best treatment option for Mr. R. The Safe Enclosure proved to be an excellent alternative to traditional restraints. It was implemented as the least restrictive device that would protect the patient from injury while maintaining his dignity and complying with both JCAHO Standards 1 and HFCA Regulations 2 .  Mr. R. was free of the restrictions of chest and limb restraints. His pressure ulcers healed as a result of his improved positioning status. The family stated they were very pleased because they were able to stop worrying about his safety and more easily participate in his care. 3

1 Joint Commission for the Accreditation of Health Care Organizations; TX.7.5, TX.7.5.2, TX.7.5.3, TX.7.5.4 and TX.7.5.5

2 Health Care Finance Administration, HHS, Regulations: CFR Part 483, Subpart B û Requirements for Long Term Care Facilities; 483.13, 483.15,

3 Submit by Susan Roos MS, RN

Case Study 101

Clinical Research: Patient with traumatic closed head injury

Mr. L. was a 33-year-old male who had suffered a traumatic closed head injury resulting in temporal lobe fracture, cervical injury and non-displaced fractures of several thoracic vertebrae. Lower extremity paralysis, prolonged coma, seizure disorder and ventilator dependency resulted from the initial trauma.

As the recovery process began, Mr. L remained in a semi-stuperous state and suffered from frequent episodes of intense agitation.  During these episodes, the patient thrashed about the bed throwing his head and extremities against the bed rails with such force that numerous bruises and lacerations developed.  More than once, he threw himself to the floor.

The nursing staff attempted to restrain the patient using chest and wrist restraints, which only increased his irritability and thrashing behavior.  Next, the restraints were removed and the bed rails were padded, but again the patient threw himself to the floor. The bed was kept in the lowest position at all times, but this made it difficult for the staff to carry out any procedures and several were treated for back pain after attending to Mr. L’s needs.

Mr. L’s family grew increasingly frustrated and angry about the situation. The nursing staff was frustrated as well, having exhausted all the traditional approaches to protect the patient while maintaining his dignity.

During patient rounds, the various options for the least restrictive restraints were explored. The Safe Enclosure bed was discussed as the only viable alternative to restraints for this perplexing case.  The family consented on behalf of the patient, and the attending physician wrote an order for the Safe Enclosure.

The Safe Enclosure proved to be an excellent alternative to traditional restraints.  It was implemented as the least restrictive device that would protect the patient from injury while maintaining his dignity and complying with both JCAHO Standards 1 and HFCA, HHS regulations 2.  Mr. L. was free to move about and his agitation was markedly decreased. The family stated they were very pleased because they were able to stop worrying about his safety and more easily participate in his care.

Joint Commission for the Accreditation of Health Care Organizations; TX.7.5, TX.7.5.2, TX.7.5.3, TX.7.5.4 and TX.7.5.5
2 Health Care Finance Administration, HHS, Regulations: CFR Part 483, Subpart B û Requirements for Long Term Care Facilities; 483.13, 483.15,
 Submitted by Susan Roos MS, RN