Face to Face Locked Orders

  1. I'm having an issue with these locked seclusion orders on my floor. I was told by management that during night shift where there is no physician and after about three pm no advanced practice psychiatric nurse then the person who needs to sign the order is a registered nurse. This supposedly has not been approved or confirmed but that is what management is telling me to do. I mean these locked orders only last for four hours. I feel extremely uncomfortable signing these orders and I had my first locked patient and the charge nurse told me that the best thing to do besides risking my license is unlocking the patient while he is asleep and hope for the best. So I unlocked him and thankfully he was fine for my shift. So what is the locked seclusion protocol for your floors I'm so confused about this topic.
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  2. 13 Comments

  3. by   elkpark
    So if there's no MD or psych APN to sign the order, who the heck is doing the face-to-face eval within one hour??? (That's how it usually works; the doc/whoever gives the order over the telephone, and then signs it when s/he arrives (within the hour) to do the face-to-face.) What your "management" is telling you to do is a violation of the CMS rules for restraint & seclusion, and the facility would be in serious trouble if this were found out. Your facility may well be violating your state rules & regs re: restraint and seclusion, as well.

    If a client is placed in behavioral restraint or locked seclusion even for only a few minutes, the CMS rules require that the face-to-face eval by a licensed independent provider be done even if the person is already out of the restraints or seclusion by the time the LIP arrives to do the eval.

    A lot of hospitals use their ED docs to sign the restraint orders and do the face-to-face evals. Or, someone has to get up out of bed and come to the hospital and do it! The CMS rules are v. clear.
  4. by   <3Nursing07
    Usually the locked seclusion orders are written during the evening shift and the physician is there and since its four hours it rolls over to the nights but then during nights we are completely screwed b/c we can't renew it. The resident for the hospital used to do the face to face but now they refuse to do it saying it is not within their scope of practice or something which makes no sense since last I heard residents all have to go through a psych rotation...but thats where we stand currently and everyone is confused.
  5. by   funinsun
    With seclusions and restraints out West I have always had the APN/Psychiatrist come do the face to face evaluation and it was pretty well done even on night shift if had to be-even if they had to drive in..
    At another facility it was made so that the RN was able to sign off on the restraint/seclusions and sign as the evaluator if needed about 6 months ago.. This policywas clearly stated in the notifications management gave to us though made us uneasy.. Dont know how they had that worked out, but even the restraint/seclusion forms had "RN" able to be circled on the form as the evaluator who did the face to face..

    Interesting...
  6. by   wrldwatchn2
    Quote from <3nursing07
    i'm having an issue with these locked seclusion orders on my floor. i was told by management that during night shift where there is no physician and after about three pm no advanced practice psychiatric nurse then the person who needs to sign the order is a registered nurse. this supposedly has not been approved or confirmed but that is what management is telling me to do. i mean these locked orders only last for four hours. i feel extremely uncomfortable signing these orders and i had my first locked patient and the charge nurse told me that the best thing to do besides risking my license is unlocking the patient while he is asleep and hope for the best. so i unlocked him and thankfully he was fine for my shift. so what is the locked seclusion protocol for your floors i'm so confused about this topic.

    [font=lucida sans unicode]:spin: rock on elkpark! i'm with you! our facility requires an md order for the first hour (with a face to face), and a face to face every hour thereafter till the point of a total four hours in locked seclusion occurs. at that point the md may order a four hour time block of seclusion before they have to perform the next face to face evaluation.
    [font=lucida sans unicode]
    [font=lucida sans unicode]i don't know what you were advised in nursing school 3nursing07, but i was taught to never perform any intervention without a facility policy and procedure in place. without one, you no longer have the protection of your employer's standard of care. in a court situation you would have to validate your actions based on prudent judgement, or a professional body that defines practice for correctional nurses validate it.
    [font=lucida sans unicode]
    [font=lucida sans unicode]the act of placing someone in a locked selusion in effect removes an individual's civil rights and needs to be monitored by an advanced practice individual for it to continue.
    [font=lucida sans unicode]
    [font=lucida sans unicode]please advocate for yourself and put in writing to your supervisors a request for a policy and proceedure related to this issue, and keep a copy. you are also within appropriate boundries to tell them you are not comfortable carrying out this task any longer till a policy is developed.
    [font=lucida sans unicode]
    [font=lucida sans unicode]please keep yourself safe!
  7. by   CharlieRN
    My facility is working toward having the nursing supervisor do the face to face on the night shift. The Doc on Call used to have to come in for it. They seem to think that it will be legal. This is important to me because the night supervisor is ME.

    I don't have issues with my competence, particularly if there are clear guidelines, but I do have questions about the legality.
  8. by   Thunderwolf
    Here is a nice chart, comparing the changes (CMS Revised Rules) .

    http://www.thenationalcouncil.org/cs...on_rules_chart
  9. by   elkpark
    Quote from Thunderwolf
    Here is a nice chart, comparing the changes (CMS Revised Rules) .

    http://www.thenationalcouncil.org/cs...on_rules_chart
    Aha! I see that CMS has knuckled under to all the whining and complaining from the docs and hospitals, and they are making it okay for RNs to do the evals. I think that is a real shame.
  10. by   Thunderwolf
    these are words of absolute wisdom.

    "[font=lucida sans unicode]i was taught to never perform any intervention without a facility policy and procedure in place. without one, you no longer have the protection of your employer's standard of care."
    -----wrldwatchn2

    i totally agree with this.
  11. by   Thunderwolf
    I think this was eventually bound to happen, elkpark. I was not totally surprised.
    Last edit by Thunderwolf on Oct 6, '07
  12. by   <3Nursing07
    Oh wow so they just changed that policy in January. Thank you for the website it answered a lot of questions for me.
  13. by   TrudyRN
    Good to know. What is the definition of an LIP?
  14. by   Thunderwolf
    Quote from TrudyRN
    Good to know. What is the definition of an LIP?
    Thanks for asking.

    A LIP is a "Licensed Independent Practitioner" who is in a collaborative practice agreement with a licensed physician....such as an Advanced Practice Nurse (APN)....for example, a Nurse Practitioner (NP) or Clinical Nurse Specialist (CNS).

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