Forcibly removing piercings in psych patients

[KathyDay]

I have a very sensitive question. I have recently learned of a patient, who is bipolar and who was having a crisis, went to the ER. There, every patient has to go through a metal detector, and security checks bags. The smaller ER across town does not do any of that. This woman had piercings, nipple and belly button and she was told to remove them. I am not sure who made that demand, but when she refused, a security guard forcibly removed them lacerating both areas. Apparently a nurse was in the room. This exacerbated the woman's anxiety and she fought back...escalating the situation and she ended up netted and medicated.

As a retired RN who worked many years in an ER, I found this appalling. If a patient refused anything I would have brought that to the attending ER doc and gone from there. NEVER would I have allowed unprofessional, untrained, brutes to forcibly remove sensitive piercings like that.

I was also told that patients in mental crisis are stripped and searched at that hospital where I use to work. Is that routine? Is that done by security people or professionally by nurses? Are male security officers allowed to do such things to female patients? Is it right that male security people stay with female psych patients even in the bathroom?

I understand that in order to protect patients from themselves if they are deemed potentially harmful to themselves, that some of these measures may be needed, but from what I was told, it seemed that patient was assaulted and that escalated her anxiety and combativeness. The results were disastrous.

Exactly what is the general policy regarding people in mental crisis? How far should security people be allowed to go? Should male security people be allowed to even touch a female patient unless she is threatening to others? Would a professional nurse first look out for the patients rights to safety and privacy and seek the doctors opinion, before allowing such a horrible scene to take place. What about calliing in professional mental health crisis workers?

I am very serious about this discussion and would love to hear from ER nurses who work with this type of issue every day.

[meanmaryjean, DNP, RN]

Color me skeptical of the original story.

[Anna Flaxis, BSN, RN]

I think it's appropriate to have patients expressing SI/HI dress down and to remove personal belongings from the room. This can include removing jewelry if the jewelry is of a nature where it could be used to cause harm to self or others. However, it is hard for me to imagine how the average nipple or navel ring could harm anyone or interfere with the plan of care in any meaningful way. As an ER RN, this is not a hill I'd choose to die on, and I'd err on the side of protecting the patient's rights.

[KathyDay]

That was my sense of things too. The person who shared this story with me was extremely angry about what happened to his fiance, but he showed me the photos of the lacerations that were caused. This woman had not been declared incompetent, or a danger, so it seemed like they went way overboard. If things happened the way they were described, this was assault and the patient's nurse did not protect her patients safety or rights.

[Munch]

We have a huge psychiatric unit as well as cpep in the hospital I work in and psych patients do go through a search before they come to the ER. But this is done in a private setting by the same sex staff member as the patient. Their belongings are removed and they change into a hospital gown. They don't have to strip down completely though, they are allowed to keep their underwear on. This is to make sure they don't have any weapons on their person to hurt themselves or someone else with later. I don't know OP it seems like they went a little to far with the patient you are talking about. In my hospital the only thing security does is wave the patient with the metal detecting wand(when they are fully clothed) to make sure nothing was missed or hidden as the searches aren't invasive. Other than that everything involving the changing of the patients clothes is done with a same sex staff member.

[JKL33]

The smaller ER across town does not do any of that.

That's really of no significance. It's just as likely they should.

This woman had piercings, nipple and belly button and she was told to remove them. I am not sure who made that demand, but when she refused, a security guard forcibly removed them lacerating both areas. Apparently a nurse was in the room. This exacerbated the woman's anxiety and she fought back...escalating the situation and she ended up netted and medicated.

First, it is not usually a "demand," (which implies the requester is irrational) but rather SOP.

We weren't there, but I personally would have tried to prevent security from becoming involved in this way. I prefer to try to talk with the patient and start to develop a rapport and basically explain our procedures and their rationales and an overview of the course of care.

As a retired RN who worked many years in an ER, I found this appalling. If a patient refused anything I would have brought that to the attending ER doc and gone from there. NEVER would I have allowed unprofessional, untrained, brutes to forcibly remove sensitive piercings like that.

I tend to agree with you and would have consulted with peers, supervisor and security in deciding how to handle.

I was also told that patients in mental crisis are stripped and searched at that hospital where I use to work. Is that routine?

That they will change into a gown and (usually) have their belongings removed from the area is routine wherever I have been. Nursing staff (RNs, techs, etc) perform this process. They are not "stripped" (again...wording), but asked to change into gown while privacy measures are taken.

What about calliing in professional mental health crisis workers?

Mental health crisis workers will agree to make plans to come and evaluate the patient....as soon as the MSE (medical screening exam) is complete, which includes ruling out anything physical cause for the situation - the patient is "medically cleared." And usually not before.

In fact, mental health agencies like to send people to the ED for the process of evaluating need for inpatient psychiatric hospitalization and/or assessing crises instead of taking care of it off-site as they used to. I don't necessarily fault them for that because there were very serious safety concerns about meeting patients-in-crisis in offices, especially after-hours.

This woman had not been declared incompetent, or a danger, so it seemed like they went way overboard.

Well, the starting point isn't to assume that patients aren't a danger. Surely you know of plenty of stories (or experienced yourself) what happens when people make assumptions like that in the course of evaluating psychiatric concerns. Patients are there so that others can evaluate the patient's condition, including the potential safety concerns. That's part of the evaluation. It would be negligent to assume that there were no safety concerns when the formal evaluation hadn't even started yet.

Being declared incompetent is a legal procedure that is often long-term with a guardian assigned.

Piercings don't seem to pose too much of a threat to anyone, but people are creative and are already in the ED because things aren't going as well as usual. The typical thing with jewelery of this type is swallowing it, for instance.

Based strictly on what you've reported, which is either second or third-hand, I would not agree with the actions of this security team. One of the most important goals for assessing psychiatric concerns is de-escalation and assurance of safety. As far as the immediate issue (the piercings) - - I don't know what to say. You have to remember that patient assurances about what will or won't happen when leeway is given are a dime a dozen and often don't end well. After things have gone wrong it's too late to have simply followed the procedure in the first place.

They should reach out to patient relations or the patient liaison regarding this matter.

[Anna Flaxis, BSN, RN]

Piercings don't seem to pose too much of a threat to anyone, but people are creative and are already in the ED because things aren't going as well as usual. The typical thing with jewelery of this type is swallowing it, for instance.

What harm have you seen swallowed nipple or navel rings cause? I'm trying to understand this, because it's not a button battery or a magnet. It's a small foreign body that will most likely pass with no adverse sequelae. Am I missing something? I'm really more curious than anything...

[angeloublue22, BSN, RN]

As a long time psych nurse including ER psych, people are more than capable of hurting themselves with piercings so they do need to be removed. We even had some use a staple to cut themselves. But no I don't think that situation was appropriate. Having males do this to a female patient who could possibly have trauma just makes things worse and creates undue injury and distress. We usually use a little more finesse to get them to remove their jewelry. Compromise and offering choices can help the situation and give the patient a feeling of control. A social worker or counselor can sometimes help. I can't believe this situation was allowed to happen. There should be protocols in place for this to provide safety to the patient and staff. It sounds pretty barbaric.

[Lev, MSN, RN, NP]

I think it's appropriate to have patients expressing SI/HI dress down and to remove personal belongings from the room. This can include removing jewelry if the jewelry is of a nature where it could be used to cause harm to self or others. However, it is hard for me to imagine how the average nipple or navel ring could harm anyone or interfere with the plan of care in any meaningful way. As an ER RN, this is not a hill I'd choose to die on, and I'd err on the side of protecting the patient's rights.

They could remove them and swallow them.

[Anna Flaxis, BSN, RN]

They could remove them and swallow them.

Again, what harm does swallowing a nipple ring do? Sure, there is potential for harm, but most of the time, they pass without incident.

[dream'n, BSN, RN]

I'm a psych nurse. Any employer I have had would have outright fired any staff member (nurse, security, etc) that had forcibly assaulted a patient like this. Sounds like the patient should call the police and make a report of assault and battery. Personally I think they have a basis for a lawsuit.

[KathyDay]

I agree. When I spoke to the man who is engaged to this woman, he felt the same way, but she was so traumatized by the assault that she was afraid. She refused to make a formal complaint to the police because she perceived them as in cahoots with hospital security. She also had a prior history of sexual abuse and this assault seriously affected her. It was a bad situation all around. Some heads certainly should have rolled in my opinion. I am a patient safety advocate and I work on safety issues on a State and Federal level. I advised this man that he should get his anger under control and try to make a difference in that ER. So, he joined with a mental health advocacy group and with his persistence, there is now a mental health crisis expert in that ER for 8 hours every day. It is a step in the right direction, but what about the other 16 hours in a day....I suppose there is just an on call expert. As a nurse I understand the need to keep the patient and also the staff safe, but this brute force, by a male on a female, smacks of sexual assault and/or abuse.