PS1013 SARASOTA MEMORIAL HOSPITAL POLICY TITLE: DISRUPTIVE PATIENT BEHAVIOR POLICY #: EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: 9/14/06 06/16/17 Clinical Non-Clinical 1 of 9 Job Title of Responsible Owner: Chief Nursing Officer/Chief of Medical Operations PURPOSE: POLICY STATEMENT: EXCEPTIONS: To provide a safe and therapeutic environment for patients and a safe working environment for members of the health care team. To allow for the discharge of patients who are violent, violate hospital rules or refuse to aid in the furtherance of their medical treatment. To administratively discharge a mentally competent patient who refuses to cooperate or who exhibits unacceptable behavior that could cause the hospital to divert its resources to activities not concerned with patient care. This policy applies only in situations where the patient is otherwise medically capable of being released or transferred in accord with reasonable medical standards. If the patient must remain in the hospital, all possible locations will be explored for the best environment to best control the situation and minimize risk to staff. If the patient is an unemancipated minor or incompetent, involvement of the legally authorized representative is required. DEFINITIONS: 1. Administrative Discharge implies that, although the optimal course of treatment would be for the patient to remain in the facility, his/her behavior has made it impossible to treat the patient and still maintain optimum levels of care to other patients. 2. Inappropriate (unruly) patient behavior is disruptive to the patient s own care, the care of other patients, and/or the general operation of the hospital. These situations include, but are not limited to: a. Refusal of patients to comply with reasonable requests from medical or nursing staff member. This includes refusal to comply with medical protocol and/or unit rules and regulations. b. The possession or the use of illegal drugs/substances on hospital premises. c. The use of alcohol and other medications or substances that are not prescribed by the treating physicians. d. Disruptive confrontations, either physical or verbal, with other patients, visitors and/or staff members.
2 of 10 e. Threats of physical assault or physical assault by patients to the nursing or medical staff and/or other patients. f. Threats of death by patients to the nursing or medical staff. 3. Basic patient rights are identified in the Florida Patient Bill of Rights and Responsibilities. At the same time, the patient is charged with various responsibilities which include, but are not limited to: a. Following reasonable medical facility regulations. b. Not disrupting the provision of care to himself/herself or other patients. c. Respecting the civil rights of other patients and the medical facility staff. PROCEDURE: The process of administrative discharge should sequentially follow a number of steps, including attempts to induce compliance and assessment of the patient s medical condition. EACH STEP SHOULD BE ACCURATELY AND PROMPTLY DOCUMENTED. Contact Risk Management for assistance and/or advice. 1. Initial documentation of behavior: a. When inappropriate behavior first occurs, the nursing staff and/or staff physician(s) should counsel the patient and document the behavioral problems as well as record that the patient was informed that such behavior is inappropriate and must cease. This documentation is essential for the preliminary determination of whether the hospital/patient relationship should be terminated. b. Instances of inappropriate or persistent non-compliant conduct should be documented by a physician or health care provider to establish a pattern of repetitive disruptive behavior or non-compliance or otherwise inappropriate conduct. c. All efforts to establish and maintain a satisfactory hospital/patient or hospital/patient relationship should be documented. d. Incidents of patient disruptive behavior should also be documented on an occurrence report and sent to Risk Management. 2. Attempts to help patient attain positive patient/hospital relationship include: a. Prior to an administrative discharge, efforts to obtain compliance from the patient should be explored. Possibilities should include, but are not limited to, counseling the patient and his/her family; involving the staff physician; consulting Psychiatry, Psychology, Social Work, and/or the Spiritual Care departments; isolating
3 of 10 the patient in a private room; limiting the patient s visitors; removing TV and telephone privileges; and confiscation of illegal paraphernalia. b. Counseling efforts should focus on the need for compliance and the consequences (i.e., discharge) of continued inappropriate behavior. c. The medical record should reflect that the patient is competent and has been told and understands that: 1) Their behavior is unacceptable and inappropriate; 2) His/her behavior prohibits continued treatment and does not meet hospital/health care measurement; 3) His/her continued action is evidence that the patient chooses to terminate the hospital/patient relationship and no longer wishes to remain in the hospital; and 4) The patient was made aware of the impact/risks or not receiving additional medical care in view of his/her present medical condition. d. Occasionally, a transfer to a psychiatric facility may be indicated and is achieved by a psychiatric consult. e. In some circumstances, it may be appropriate for the patient to be placed under a Baker Act, provided the patient is assessed and meets criteria. 3. Assessment of medical condition: a. If, after appropriate counseling and warnings, the patient continues the unacceptable behavior, then the patient s medical condition should be assessed. b. If it is determined that administrative discharge would result in substantial physical harm to the patient, administrative discharge is not a feasible option and other options should be considered. c. If administrative discharge is medically feasible, it should be pursued. This assessment is necessary to minimize the liability exposure of the hospital and medical staff. 4. Medical assessment: a. A thorough physical assessment of the patient should be conducted and documented in the medical record by the attending or treating physician evaluating the patient s physical and mental condition prior to discharge. b. All appropriate diagnostic tests should be ordered, performed and results communicated to the patient, if feasible, prior to discharge. c. The attending or treating physician should make a determination based on their clinical judgment and document that the patient s medical condition is such that discharge is not likely to result in serious physical harm to the patient,
4 of 10 5. Other options: a. When discharge is not medically feasible, and all less severe remedies (including isolation) have failed, the appropriate course of action may be to physically restrain the patient. This should be done in accordance with the hospital s policy regarding restraints. b. When the disruptive patient must remain in the hospital for medical reasons, a care planning conference should be initiated to evaluate the most effective way to address the medical needs and behavioral issues. The team should include the attending physician as well as representatives from Nursing, Behavioral Health and Risk Management. c. In such cases, the hospital may risk violating the patient s rights. However, it presumes that the patient is being medically treated and properly cared for and is preferable to the risk of injury or death which could occur due to the administrative discharge or by the patient s continued behavior. d. Each step taken is to be documented in the patient s medical record. 6. Discharge from the hospital: a. When the patient s medical condition permits, according to the attending physician or his/her designee) and all other efforts to induce compliance noted above have failed and have been documented, he/she may be administratively discharged rather than restrained. The following procedure should be carefully followed and each step documented: 1) Contact Risk Management. If Risk Management, the medical and nursing and administrative staffs all concur, the patient may be discharged. 2) The team will determine if a patient advocate should be appointed to aid the patient in their assessment and understanding of this policy, their behavior and its implications as well as represent the patient s interests in an objective non-confrontational fashion. 3) The medical administrator on call should write an order for administrative discharge. The order should document that the patient s medical condition is such that referral elsewhere will not likely cause substantial harm to the patient.
5 of 10 4) The physician should explain to the patient the following points, and the medical record should reflect that these points were explained to the patient and that the patient demonstrated an understanding of the discussion. a) That the patient s repeated unacceptable behavior evidences the patient s intent to terminate the hospital/patient relationship. b) An explanation of the patient s current medical condition, the type of care which should be sought by the patient, and the timeframe within which such care should be obtained. c) A referral, when appropriate, for the patient to seek further medical care. d) An explanation that, although the current hospital/patient relationship is terminated, the patient will not be denied emergency medical care in the future. e) Discharge instructions should be given to the patient and documented in the patient s medical record. f) In appropriate cases, one or two days (or longer if deemed necessary) worth of medications may be given to the patient with an explanation that the sole purpose of the medications is to hold the patient over until he/she has sought medical care elsewhere. g) Assistance with any discharge planning needed to ensure continuity of care out of the hospital should be provided as appropriate. 5) The patient is then asked to leave the facility. Each case is different, based on the specific facts. It may become necessary to involve the Security department to escort the patient out of the facility. This should also be documented. 7. Subsequent treatment of patients who have been administratively discharged: a. When a patient who has been administratively discharged subsequently presents himself/herself for treatment at an ambulatory setting, the physician must use his/her discretion. He/she may either treat the patient or refer the patient to another facility for treatment. b. If the administratively discharged patient seeks care in the Emergency Department, a medical screening exam will be performed to determine the appropriate treatment. c. If hospitalization appears necessary or desirable,
6 of 10 consideration should be given to transferring the patient elsewhere whenever the patient s medical condition permits. All transfers must be handled in accordance with applicable policies and procedures. d. The physician may refer the patient elsewhere for continued medical care based upon the premise that the patient previously had demonstrated that he/she is unwilling to enter into a satisfactory hospital/patient relationship. e. The treating physician should document that in his/her opinion the patient s condition is such that referral elsewhere for treatment is feasible. f. If a patient who has been administratively discharged must be admitted as an inpatient, the admitting and discharge departments should consult with the nursing department regarding the patient s assigned location. RESPONSIBILITY: The vice president/chief medical officer and the vice president/chief nursing officer shall have day-to-day administrative responsibility for this policy and the administrative responsibility for this policy. The Team responsible for the review of each case shall consist of the unit manager/director, risk manager, chief executive officer, chief operating officer, chief medical officer and chief nursing officer. REFERENCES: AUTHOR(S): ATTACHMENT(S): SMHCS Policy. (2015). Rights and Responsibilities (Patients/Residents). (00.RSK.19). SMH: Author. Jan Mauck, Chief Nursing Officer R. Stephen Taylor, M.D., Chief of Medical Operations Rae DaPrato, Director Risk Management Guidelines for the Management of Disruptive Patient & Visitor Behavior
7 of 10 APPROVALS: Signatures indicate approval of the new or reviewed/revised policy. Committees/Sections/Departments: Date Director/Responsible Owner: Director/Responsible Owner: Vice President/Executive Director: Connie Andersen, CNO 5/30/17 R. Stephen Taylor, M.D., CMO 5/31/17 Chief of Medical Operations: (if clinical policy or appropriate) Chief of Staff: (if clinical policy or appropriate) Medical Executive Committee: (if clinical and review requested by CMO and COS) Chief Executive Officer: David Verinder, CEO 6/9/17
Guidelines for the Management of Disruptive Patient & Visitor Behavior Intensity Subject Behavior Suggested Actions De-escalation & Consultation Family/visitor(s) is not unified in opinion. No clear leader. Discontent among family/visitor(s) members. Staff has not responded appropriately/timely to family/visitor(s) questions, care, etc. Visitor/patient or staff apprehensive of visitation by another member. Complaints from other staff members. Family/visitor(s)/staff requests second opinion about another s behavior. Notify Charge Nurse/Clinical Coordinator on unit. If necessary, move to a private room for discussion. Provide family/visitor(s) with unit expectations and answer any questions they may have. Consult with Public Safety (xsafe). Charge Nurse notifies unit s main desk of issue to help screen. Consider Care Conference (consult with ICM). Consider psych consult (either MD or Nursing). Consider Behavioral Plan of Care for Patient (see attached example). Notify Clinical Manager or supervisor. Urgent Response or Code Grey Family/visitor(s) appears to be under influence of substance(s). Verbal conflict with family/visitor(s) or staff. Visitor threatens legal or other actions. Physical Aggression observed. Staff feels threatened. Verbal shouting, inability to continue nursing care. Refusal to leave. Presence of weapons. Notify Charge Nurse/Clinical Coordinator on unit. Call to Public Safety (xsafe) by Charge Nurse to meet on unit to discuss situation (see attached for scripting examples). Notify Clinical Manager or supervisor. Physician contacted. Family/visitor(s) may be asked to leave the premises via Public Safety escort. Consider Care Conference. Consider psych consult (either MD or Nursing). Consider Behavioral Plan of Care for Patient (see attached example).
9 of 10 Suspicion of contraband or weapons Concerns about contraband or weapons with patient or visitor. Notify Clinical Manager/Supervisor. Call Public Safety for consultation: 1. Discuss your concerns with public safety officer. 2. Establish plan with public safety officer to discuss plan with patient or visitor. (For example: what will the public safety officer say and what will the staff person say to the individual of concern). 3. Use key words upon introduction we are concerned about your safety. Always ask for permission first. 4. Public Safety will perform any searching if deemed necessary. 5. Upon findings determine and set expectations necessary to ensure safety. 6. Document plan in medical record, highlight expectations on whiteboard/paper in patient room to establish consistency and safety. 7. Provide patient with a paper copy of expectations (see attached example). Consider Public Safety presence when discussing expectations with patient/visitor. Behavior Plan of Care Contract Contract or Plan of Care for Behavior Management may include: 1. Regulation of visitation/supervised visits. 2. Monitoring of items in room. 3. Regulating special privileges. 4. Frequent rounding by public safety. 5. Administrative discharge. Once it has been identified that a contract or plan of care for behavior management is necessary consider the following: 1. Every plan is individualized and therefore the participants and steps required may vary on the individual needs. 2. Consult with Clinical Director, ICM, patient s physician and Risk to start. Others consultants may be recommended based on individual needs and recommendations. 3. Upon findings determine and set expectations necessary to ensure safety. 4. Document plan in medical record, highlight expectations on whiteboard/paper in patient room to establish consistency and safety. 5. Provide patient with a paper copy of expectations.
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