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