Can You Refuse A Patient Assignment

[gladtobeOB]

Had An Incident Last Week Where I Work, Small Hospital With Nursing Home Included In Which A Man Well Known To This Facilty Came In Seeking Psychiatric Help. (we Do Not Have The Capacity Or Doctors To Care For This Specialty). He Had Homicidal Ideations In The Er, Hx Of Being Bipolar, Hopped On Every Known Drug But Heroin. Stated In Er He Would Kill Everyone There In Er If Cops Were To Become Involved. So As The Story Goes He Was Admitted To The Floor Dx Recurrent Headache(which Obvously Had Since He Was So Jacked On Drugs) And Homicidial Ideations To The General Med/surg Floor For A 1:1.

Many Other Things Happened To Long To Write But What I Am Wondering Is If I Could Under The Nursing Practice Act Refused To Accept This Patient Under My Care With Such Statements And With The Potential To Harm Everyone That May Have Been In That Hospital At The Given Time?

Your Advise Would Be Greatly Appreciated.

[cenote]

My first instinct on reading this is that you could certainly try to refuse the assignment but i doubt you would get very far. As a med-Surg nurse you should be able to deal with a patient with a recurrent headache. Also you should have had at least some pysch training (it is mandated that you ask about thoughts of suicide or self-harm here at our hospital). So essentially you are treating his pain, monitoring his detox, and assessing for underlying symptoms that could cause headache - stroke, meningitis, etc.

If such a patient had been admitted at my facility I would have had a quick talk at the start with him - essentially emphasizing the fact that if he threatened anyone here I would call the police. If he threatened to hurt anyone here because I call the police i will restrain him and then call the police. You can't let crazy dictate your treatment or limit your options - it never works out.

Finally I am betting, since my ER has tried this a time or two, that since no beds were available in surrounding psych units that the ER did not want to be stuck with this patient they came up with a handy medical diagnosis to get him admitted - I have had them say we want to admit with hypokalemia (K is 3.2) simply because they don't want to watch him themselves.

Hope this helps

Pat

I'm sorry but "have a quick talk at the start with him" is not the answer. Having worked with this type of patient, I know that reasoning doesn't work....they are mentally ill and have lost the power of reason. Therefore, it it mandatory that the police be called. And yes, the nurse has the right to refuse this patient based on what the law terms as a "reasonable expectation" that violence will occur and of course, lack of training in the area of psychiatric nursing. The correct action in the ER would have been to call law enforcement and I'm at a loss as to why this wasn't done. Be that as it may, the receiveing nurse can and should call on the Nurse Super and refuse the assignment. If there are any repercussions, the nurse has a very good defense and the hospital , and especially the ER Doc (and I have consulted two ER Docs on this), will have hell to pay explaining why they did not call the correct authorities. Liability has been assigned when a nurse has not recognized that a patient has homocidal ideations.

[patwil73]

I'm sorry but "have a quick talk at the start with him" is not the answer. Having worked with this type of patient, I know that reasoning doesn't work....they are mentally ill and have lost the power of reason.

Yes, many are - and hence a "quick talk" can weed out those who truly have a deep mental illness and those who are trying to play the system. If they can't be reasoned with or are unwilling to listen to reason, then restraints are a go.

Therefore, it it mandatory that the police be called.

And what exactly will the police do if he truly has a psychosis? I have often had police here refuse even a drunk until medically cleared. They are not going to throw a medically ill person into the jail regardless of provocation. They will most often insist on some type of placement.

And yes, the nurse has the right to refuse this patient based on what the law terms as a "reasonable expectation" that violence will occur and of course, lack of training in the area of psychiatric nursing.

But the nurse is not truly doing psych nursing. S/he is caring for a medical patient (detox and HA). When the patient is medically stable and a bed opens up then he can be transferred to an inpatient psych bed. Also under your "reasonable expectation" a nurse can then refuse an assignment when a patient is confused from a high sodium or hepatic encephalopathy, or cirrhosis, or liver disease. Any of those can present with confusion exhibited as violent tendencies.

The correct action in the ER would have been to call law enforcement and I'm at a loss as to why this wasn't done.

And perhaps it was done and the police asked if the patient was medically cleared to leave the hospital. If the answer was no, then they would not have arrested the patient.

Now instead of refusing, there are a lot of things the nurse could have done. 1) a doctor should determine if the person has the mental capacity to make medical decisions and 2) is this person an involuntary hold? The answers here will help determine what you can do. if 1 is no and 2 is yes, then restrain and provide medically necessary treatments (many of which will mellow the guy out).

If 1 is yes and 2 is no, have the police come and pick him up for threats against staff.

If 1 is yes and 2 is yes, restrain him but allow him to decide if he will take medications and treatments.

During treatments have the nurse enter with another person to help. Leave name badges outside the room. Allow no visitors. Ask for help during and treatment you are unsure of.

I am sorry but from the limited information in the OP I stand by my answer. The nurse could try to refuse (heck s/he might even get away with it), but I don't think it would fly after the first time.

Pat

[GrumpyRN63, ADN, RN]

Whoever was charge should have refused the admission to the unit and informed clinical/nursing administration. The pt should have been left in the ED on a 1:1, restraints, crisis lockdown, whatever they do down there (not a psych nurse) but no way in he** would have a homicidal/violent threatening pt have been admitted to my unit. I would have taken him if he was only detox. What is the policy? I know I wouldn't have ever been in that position, our ED handles this all the time, but how awful for you

[akai6]

I fell into this situation today. Not refusing an assignment, but refusing to travel to another hospital that I was not on call for.

I was told I was not going to be needed after I was finished running a dialysis treatment on a patient, because I would be needed all day the following day. Once a new patient was admitted at that facility I was all of a sudden needed and called. I repeat I was not scheduled to be on call and because I refused, I was suspended for the weekend and told that I would have to report to the office @ 8am on Monday.

I am now thinking that I will be losing my job... I dont know what to do... It is unfair that I would be told to go even though there was another nurse capable of going.

Now what do I do if I fired? Can they do this?

[wonderbee, BSN, RN]

In my opinion, it is better to lose one's job than one's license. It's a judgment call a nurse makes on the spot. It's a call made knowing that it could cost your job. Yes, the Nurse Practice Act gives us the right to refuse an assignment. Once you've taken report though, you cannot refuse.

I have had to refuse to take report for unsafe staffing. It was impossible to make it work. It's a stand I hated to take and I knew full well the possible consequences. Fortunately, the needed staffing was provided however I was relieved of my charge role for that shift. I still abide by my decision and hope others will take my lead when it's just not safe.

[KaliNurse]

These stories, once again, reiterate the overwhelming responsibilities of the RN. Considering the status of the current healthcare situation, I don't see very much changing in the very near future. Hospitals are downsizing staff to save $$, and nurses are becoming more and more responsible for these kinds of issues. Unfortunately, liabilities such as these stories continue to plague our healthcare system. Hopefully, I am wrong, and we will see some needed changes down the road!

[ellemae8]

I was just looking for some advice on a situation I have at work .. I work in home care and I started looking for a new position when my previous employer would only schedule me at one clients house and i would be there for 6-8 hours a day. now this family was very religious and I have no problem what so ever with people and the religion they choose if any but when the grandmother who lived at this house and the father started trying to push religion on me i became very uncomfortable and felt very harassed they even went as far as to tell me why the religion i choose to follow was wrong. also the other child would call me fat and all sorts of other names i told my employer about the situation and they said i was the only nurse this family liked coming into the home and working so basically i was out of luck. well i found a new job and thought i was free and clear of this family and was so happy about this well now they have moved to the new agency i work with and i am having anxiety attacks that my new employer will try to send me to the same house. Am I able to refuse to take this family on as clients ????

[Crash_Cart]

Some patients in distress say the darnedest things...

In my own experience working in an ER, I found it's not particularly out of context to hear these or similar words on occasion.

However, I would base any refusal to provide them treatment or care based on previous actions and not their history of words spoken.

So what does the patients history tell you? Did they cause any actual physical harm to nurses in the past?

I found in the majority of these instances, the patient is merely playing a game to elicit a desired response. It's a game to them because it instills fear and makes them feel in control over the nurse. Your refusal to provide them care may in fact be the intended desired response.

Again, what is the patients physical harm track record?

Just something I would take into consideration in this refusal of care scenario.

Also you might be interested to know that criminal charges involving verbal threats rarely work in these instances because the legal system takes into consideration the mental status of the person making the threats.

Ask yourself if it would be reasonable for any court to criminally charge a mentally ill person making death threats who has a clear diagnosis and who is institutionalized? ...I doubt it.

However, the public does have an expectation that they are taken care of unless there is a history involving PHYSICAL harm. If that is the case, then the matter is up to law enforcement and they would be under "their" care.

Sounds to me they are using a lot of big scary words and no actual physical harm was done to anyone. If they did, this individual would already be in jail and not admitted to any hospital facility.

My Best,

[RNMLIS]

I have experiencd this in LTC. We used to say that the facility would take anyone..we frequently had such patient admited on 3-11 with no meds...the night crew is left to deal with a confused, fearful, threatening, mentally disturbed angry person. The staff is not trained to care for these cases and the staffing level does not permit safe care for these individuals.

If the MD is called for meds. to calm the patient -first, he is angry about being disturbed and usually will not perscrbe anything as "I have not seen the patient"

I have been hit attempting to deal with the situation. If the staff or others are harmed the pt. goes out to psch. admit. where they may have belonged in the first place...what a waste - who does one refuse to?

The LTC facility I worked for often walked a fine line and they seem to get away with such reckless behavior....This is playing with the safety of the patient and others. As they tend to 'get away with it' they are 'encouraged' to do it again.

When the DON came in after I was hit and sent this poor scared man out, she said that she thought he might have to be sent out - WHAT ^@$UOUO!!!