Current through Register Vol. 48, No. 12, March 22, 2024
a)
Residents in Need of Emergency Mental Health Care
1) When medical, treatment or security staff
believe a resident is in need of emergency mental health care to prevent self
injury, the AOD shall be notified.
2) The AOD shall immediately initiate
placement of that resident into Mental Health Status 1 and provide continuous
observation of the resident.
b) Resident Placement, Property Restriction
and Observation Requirements
1) Placement.
After placement in Mental Health Status 1 is initiated, and prior to the
completion of the one-hour assessment by an MHP, the resident shall be placed
in an empty, designated observation room. Following the one-hour mental health
assessment, continued room placement of the resident shall be determined by
consultation between security staff and the MHP assigning the resident to
Mental Health Status 1 or 2. The decision regarding where to place the
resident, and his/her movement while on Mental Health Status, shall be based on
the level of risk the resident presents, as well as the institutional
management challenges presented by the resident once placement is
initiated.
2) Property. During
initiation, the AOD may limit or restrict the personal or facility-provided
property items, including clothing, the resident is permitted to possess. Once
the mental health assessment is complete, the MHP assigning Mental Health
Status shall indicate the appropriate, allowable personal or facility-provided
property. This decision shall be approved by the Program Director.
3) Observation. The resident shall be under
continuous visual observation once these procedures regarding Emergency Mental
Health Status (EMHS) are initiated, and will remain under continuous visual
observation until, in the opinion of an MHP, observation is not
necessary.
c)
Notification of Clinical Director or Designee
1) As soon as practicable, the AOD will
notify the Clinical Director or designee that EMHS was initiated and shall
request that an assessment of the resident's behavior be performed by an
MHP.
2) If the need to initiate
EMHS occurs when there is no MHP on-site, the AOD shall request that the duty
nurse perform the assessment.
3) An
on-site assessment of the resident's mental health needs shall be performed
within one hour after placement in EMHS.
4) If EMHS is initiated after normal business
hours, upon completion of the one-hour assessment, the duty nurse shall notify
the Clinical Director or designee.
5) In all situations, an MHP will become the
lead person in management of the resident through resolution of the crisis. The
MHP will determine necessary interventions, including the need for continued
observation, the type of observation, the need for a psychiatric consult,
and/or any other appropriate mental health interventions. All measures taken
shall be documented in the resident's clinical file.
d) Contacting Psychiatrist on Call
1) The Clinical Director or designee may, at
his/her discretion, contact the psychiatrist on call and consult with him/her
regarding the resident's apparent emergency mental health care needs.
2) The Clinical Director, AOC and
psychiatrist on call, within their respective scopes of practice, shall
determine the utility of emergency medication; the interval, frequency and type
of observation (e.g., medical, general, security); room placement; and
permitted property. They shall also direct the security staff and health care
staff accordingly.
e)
Minimal Standards for Care and Observation
While the resident remains in EMHS, the following are minimal
standards for care and observation, unless otherwise directed:
1) The resident will be reassessed by an MHP
or the duty nurse every shift while on EMHS.
2) Security and nursing staff shall follow
all instructions from the Clinical Director or designee.
3) To assure continuity of care, the MHP or
duty nurse shall, every shift, write a summary progress note that includes
assessment, care and status of the resident. This note shall be placed in the
resident's clinical file.
4) In all
cases, the resident shall be evaluated face-to-face by an MHP, within 24 hours
after being placed on EMHS, to determine the resident's continuing
needs.
5) A resident may not be
placed on EMHS for more than 24 hours unless continued by an MHP after
conducting a face-to-face assessment of the resident.
6) Residents placed on EMHS shall be
restricted to the living unit or healthcare unit and may only leave the unit
for medical reasons, court writs, or as otherwise approved by the Program
Director. All residents on EMHS shall be provided a 1:1 escort while off the
living unit.
7) When a resident has
been on Mental Health Status for a continuous period of 72 hours, the Clinical
Director or designee shall review the resident's ITP with the facility
psychiatrist. If the resident is continued on Mental Health Status, the
psychiatrist will conduct a face-to-face evaluation of the resident and, with
the treatment team, shall review the ITP weekly for the time the resident
remains on Mental Health Status. A resident's ITP shall:
A) address individual behaviors and special
needs;
B) address the need for
special observation; and
C) provide
guidance to staff who provide for the daily care and treatment of the
resident.
8) All direct
care staff shall follow the specific guidelines set forth in the ITP,
including, but not limited to, behavior observation, data collection,
documenting intervals, and interaction with the resident and the resident's
response. This shall occur while the direct care staff continues to provide all
other day-to-day care and treatment of the resident.
f) Incident Reporting Requirements
The AOD will ensure that the staff involved in the incidents
leading up to the initiation of EMHS complete incident reports or chart notes
as needed before they leave their shift. The shift supervisor shall ensure that
all incident reports are delivered to the Program Director before the end of
his/her shift.
g)
Notification of Resident's Reassignment
1) On
the first subsequent business day after a resident reassignment, the Clinical
Director or designee shall notify the resident's primary therapist and facility
psychiatrist of the reassignment and the behavior necessitating placement on
EMHS.
2) On the first business day
after placement on EMHS, the Clinical Director, primary therapist, or facility
psychiatrist shall review the resident's continuing need for emergency mental
health care.
A) If there is evidence of
continued risk, the resident shall remain on EMHS. Continued assignment to EMHS
shall then be reviewed every business day thereafter until the resident is
reassigned to a different management status.
B) If, upon review, there is no evidence of
continuing risk, the resident shall be returned to his/her previous management
status with recommendations for follow-up treatment.
C) If the Clinical Director, primary
therapist or facility psychiatrist determines the resident presents a risk of
harm to self or others that is not related to his/her mental health, the
resident will temporarily be reassigned to Special Management Status.
D) In the event of a re-assignment of the
resident to Special Management Status, the Clinical Director, primary
therapist, or facility psychiatrist shall notify the AOC and refer the matter
to the Behavior Committee for review.
E) When a resident is temporarily reassigned
to Special Management Status, the requirements specified in the Special
Management Directive will be followed.
h) Daily Contact with Resident by Primary
Therapist
1) While a resident is on EMHS,
his/her primary therapist shall have daily, individual contact with that
resident. The contact shall, at a minimum, involve:
A) Assessment of the resident's current
dangerousness;
B) Mental status and
mental health needs; and
C) The
coordination of physical or medical needs, as required.
2) The primary therapist shall discuss the
events and decisions resulting in the resident's reassignment to EMHS. Those
events and decisions shall be viewed in light of the resident's overall ITP
and, as appropriate, the ITP shall be modified and additional treatment
recommended to reduce the frequency of the resident's reassignment to EMHS. The
resident's primary therapist is responsible for ensuring that the resident is
offered the following:
A) Daily recreation
time as appropriate, based on the resident's mental status and assessed
dangerousness;
B) Adequate access
to personal hygiene and grooming supplies; and
C) All permitted personal and
facility-provided property.