Ohio Administrative Code
Title 5122 - Department of Mental Health and Addiction Services
Chapter 5122-3 - Electroconvulsive Therapy; Incident Reporting; Patient Abuse/Neglect; Etc
Section 5122-3-12 - Duty to protect
Universal Citation: OH Admin Code 5122-3-12
Current through all regulations passed and filed through December 16, 2024
(A) The purpose of this policy is to implement the duty to protect requirements per section 2305.51 of the Revised Code.
(B) This policy shall apply to all mental health professionals employed or contracted by Ohio department of mental health hospitals.
(C) Definitions:
(1)
"Independently-licensed mental health professional" means psychiatrists,
psychologists, social workers, counselors and clinical nurse specialists
licensed to independently provide mental health services.
(2)
"Knowledgeable
person" means any person who has reason to believe that a patient has the
intent and ability to carry out an explicit threat of inflicting imminent and
serious physical harm to a clearly identifiable potential victim(s), who is
either an immediate family member of the patient, an employee of the hospital,
or an individual who, otherwise, personally knows the patient.
(3)
"Mental health professional" means any individual who is licensed, certified or
registered under the Revised Code, or otherwise authorized in this state, to
provide mental health services.
(D) Procedures:
(1) Any mental health professional to whom an
explicit threat of serious physical harm to another person or persons or
identifiable structure is made, or who is made aware by a knowledgeable person
of an explicit threat made by a patient, will initiate the duty to protect
process.
(2) Any explicit threat
by a patient shall be promptly communicated by the mental health professional
who heard the threat or was made aware of the threat, to a registered nurse or
psychiatrist on the patient's treatment team. The treatment team shall
determine, based on the patient's history and current condition, whether the
threat represents a credible danger to others.
(a) If the treatment team does not consider
the threat to be a credible danger to others, this decision and the reason for
this determination shall be documented in the medical record.
(b) If the treatment team considers the
threat to be a credible danger, the threat shall be reported promptly by the treatment team to the chief clinical
officer or designee of the hospital.
(3) The chief clinical officer or designee of
the hospital shall assign an independently-licensed mental health professional
to conduct a face-to-face evaluation with the patient as soon as possible after
receiving notification of the threat, but no longer than two working days, in
order to give a second opinion risk assessment of the threat.
(4) If the independently-licensed mental
health professional determines that the threat does not meet the threshold
requiring discharge of the duty to protect (e.g., threat is not imminent), this
assessment should be documented on a form authorized by the
regional psychiatric hospital (RPH) or in a
progress note in the medical record.
(a)
Each RPH shall establish policies and procedures that
assure patient re-evaluation occurs prior to the patient being discharged or
receiving unsupervised movement, including placing a "Duty to Protect" sticker
on the patient's chart and adding a "Duty to Protect" problem on the treatment
plan. (See Appendix 1 [DMH-0040a] for "Duty to Protect Tracking Form" which may
be used by the RPH to monitor procedure compliance).
(b)
The independently-licensed mental health professional shall record, in a
progress note or indicate on a
RPH form, that the patient does not have either
the intent or ability to carry out the threat and record the reason(s) for this
conclusion.
(c) Other clinical recommendations may be considered
for this patient and should be documented as appropriate in the medical record.
(5) If the
independently-licensed mental health professional determines that there is an
explicit threat of imminent and serious physical harm and there is reason to
believe the patient has the intent and ability to carry out the threat, the
independently-licensed mental health professional completing the
RPH form
or documenting this assessment in a progress note in the medical record, must
address each of the relevant options to discharge the duty to protect in
section 2305.51 of the Revised Code and
indicate the reason(s) each was, or was not, chosen.
(a) Since the patient in these instances is
already hospitalized, the relevant options for further action under section
2305.51 of the Revised Code for
discharging the duty to protect are as follows:
(i) Establishing and undertaking a treatment
plan that is reasonably calculated to eliminate the possibility that the
patient will carry out the threat (having performed this second opinion risk
assessment consultation); and
(ii)
Communicating to a law enforcement agency either where the victim or patient
resides and, if feasible, communicating with the potential victim(s)
and/or
guardian(s) about the threat;
(b) If the option chosen by the
independently-licensed mental health professional is to warn the potential
victim(s) and appropriate law enforcement agency, the independently-licensed
mental health professional shall notify the chief clinical officer (or
designee) who will designate the person to give the warning;
(i) The information about who was warned,
what information was shared, and the time of the warning shall be documented on
the RPH
form (Appendix 2 [DMH-0040]) or in the progress
note in the medical record; and
(ii) Information shared should be restricted
to the name and the description of the patient, the nature of the threat, and
the name of potential victim(s) and/or potential structure threatened.
(6) Progress
notes in the medical record should reflect any contacts with consultants, chief
clinical officer (or designee), or the patient's treatment team as appropriate.
(7) The RPH authorized
form, or a copy of the progress notes about the threat should be filed in the
legal section of the medical record. A copy should be forwarded to the legal
assurance administrator of the hospital.
(8) If the threat is considered to be serious
but not imminent, and the independently-licensed mental health professional
believes the threat should be re-evaluated closer to unsupervised movement,
conditional release or discharge of the patient, the independently-licensed
mental health professional will contact the treatment team social worker who
will affix or cause to be affixed, a prominent sticker on the front of the
patient's medical record noting a "Duty to Protectr" and add a "Duty to Protect" problem to the treatment
plan.
(9) When a "Duty to
Protect" sticker is affixed to the medical record and a
problem is added to the treatment plan, prior to unsupervised movement,
conditional release or discharge, the treatment team social worker will notify
the chief clinical officer (or designee) who will assign an
independently-licensed mental health professional to conduct a face-to-face
re-evaluation of the presence or absence of the threat, and if present, the
credibility of the threat.
(10) If
a patient with a "Duty to Protect" problem goes
AWOL from a RPH, the treatment team (or on evenings, weekends, and
holidays, the nurse manager) shall promptly give a recommendation to the chief
clinical officer regarding warning law enforcement and, if feasible, potential
victims in the community.
(11) In
all re-evaluations, the independently-licensed mental health professional
should locate the original
RPH form or progress notes about the threat in
the medical record or in the file of the legal assurance administrator.
(a) After the face-to-face re-evaluation, a
new RPH
authorized form or medical record progress note shall be completed and filed in
the legal section of the medical record with a copy to the legal assurance
administrator.
(i) If no active serious
threat is present, this should be noted on the RPH form or in a
progress note and no further formal action is necessary;
(ii) If an active, serious, and imminent
threat remains, this should be documented on the RPH form or in a
progress note
and the
actions identified in paragraphs (D)(5) to (D)(7) of this rule should be
followed. In addition, the independently-licensed mental health
professional shall promptly notify the treatment team for appropriate action
regarding the pending unsupervised movement, conditional release, or discharge.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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