Holding voluntary patients - illegally?

Specialties Psychiatric

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I work at a locked psychiatric hospital with acute psych, detox, and gero-psych units. We have a mix of voluntary and involuntary patients.

When working on the detox unit, nearly every patient is voluntary and, it's not uncommon to have patients request to leave AMA for various reasons (often, the patient admits they're not ready for sobriety). These are not patients that can be placed on a legal hold as they are not a danger to themselves or others and are able to care for themselves.

The problem is, as we are a locked facility, patients are forced to remain in the hospital as we process their discharge paperwork. This includes receiving a doctor's order, meeting with case management, etc. This often results in a patient asking to leave AMA early in the AM and not leaving the hospital until nearly 3pm.

We are a for-profit hospital and, at times, many employees (new nurses, non-nurse case managers, social workers) enforce the rules of the facility that to me appear to be illegal. One consent signed on admission used to state that patient's wishing to AMA must let someone know prior to 3pm in writing or else they must remain in the hospital until the next day. Other rules include requiring patients to have a medical H&P prior to discharge (even if they admitted themselves for detox and have already been assessed by a psychiatrist) and not being provided scripts on discharge if leaving AMA.

I've tried looking through my state's statutes (Nevada) to find out if this is illegal. To me, it appears to be false imprisonment as, in a non-locked facility, these patients could merely walk out the front door.

Can anyone advise on this?

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Different states have different specific rules/laws about this, but, in my experience in multiple states over my career in psych, every state I've been in has had some kind of mechanism to attempt to balance out the civil rights of voluntary psychiatric clients in inpatient settings and the state's interest in keeping people safe. In many states, that rule involves "72 hours." In my current state and in the state in which I previously spent most of my career, voluntary admissions who wish to be discharged before the physician feels they are ready have to request discharge in writing and turn that in to any staff member. At the point (precisely; if it's 2:18 AM that the individual gives the written request for discharge to a staff member, the 72 hours is up three days later at 2:18 AM), a "clock" starts running. The facility has a maximum of 72 hours to continue to hold the individual against her/his will in order to make a determination about whether it's safe to discharge the person. The facility doesn't have to keep the person the entire 72 hours; the individual can be released right away, or at any point during the next 72 hours, that is at the discretion of the attending physician. However, by the end of the 72 hours, the facility either has to release the individual or find that s/he is dangerous enough to meet the state criteria for involuntary commitment, and petition an involuntary commitment in order to be able to continue to hold her/him. Whether or not facilities abuse the legal process (keep people in the hospital longer than necessary just to make money off them, for instance) is a different issue.

Requiring an H&P on all admissions is not unusual; in fact, it is a CMS and JCAHO requirement and the facility will get in trouble with the state and federal regulatory agencies if they are not getting them done consistently. And it's not that unusual to not give discharge prescriptions to someone who is leaving AMA. The act of signing out AMA is, essentially, declining treatment.

I'm sure the Nevada Division of Mental Health, or whatever it's called in Nevada, could fill you in on the legal process in Nevada, or at least direct you to where you can find the information.

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elk, how can you legally keep a voluntary pt against their will? especially detox.

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elk, how can you legally keep a voluntary pt against their will? especially detox.

You do it as I described above (although the details and process vary somewhat from state to state). In the case of a detox client, it would depend on whether the person is admitted to a psychiatric facility or a general medical setting, and/or whether detox counts (legally) as a "psychiatric" admission within a psychiatric setting in a particular state. AMA discharges are handled differently in psychiatric settings than people signing out AMA from a regular medical facility/admission because of safety concerns (because people who want to sign out AMA from a psychiatric facility often want to do so in order to go home and do something like harm or kill themselves). In the states in which I've practiced, there's no requirement to hold people against their will if they're requesting to leave a psychiatric facility, but there is a legal mechanism to allow the attending some time (typically, a maximum of 72 hours) to make a determination about whether or not it is safe to let the individual go.

Psychiatric settings are a whole different ball game (and different set of rules) than general medical settings. For that matter, people can be detained against their will in medical settings if an attending physician determines they lack, at the time, the mental capacity to make an informed decision about leaving.

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I suppose it is a question I can approach the state division of mental health about. Or my nursing board?

To my knowledge, there is no separate designation for a "psychiatric admission" when patients come in voluntarily for discharge.

I guess my straight-forward question is: is there a legal precedent allowing me to refuse to unlock the facility's door for a patient with no indication (either immediate or within their entire chart) to be placed on a legal hold?

You may be right that I have to go a little further/higher within the state government. I just assumed this would be a question someone here could answer.

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I suppose it is a question I can approach the state division of mental health about. Or my nursing board?

To my knowledge, there is no separate designation for a "psychiatric admission" when patients come in voluntarily for discharge.

I guess my straight-forward question is: is there a legal precedent allowing me to refuse to unlock the facility's door for a patient with no indication (either immediate or within their entire chart) to be placed on a legal hold?

You may be right that I have to go a little further/higher within the state government. I just assumed this would be a question someone here could answer.

My reference to "psychiatric admission" was wondering whether a detox client in a locked psychiatric facility might somehow have some different status/designation than the people admitted for clearly psychiatric reasons that might legally affect the process for leaving AMA, since you and morte specifically mentioned detox clients.

As I said, the laws and processes vary from state to state. I can tell you precisely what the law is in the state in which I'm licensed and practicing, but I have no idea what the rules/regs in Nevada are. Maybe someone from Nevada will come along here who can answer your question; but I would bet my next several paychecks that the process in a locked psychiatric facility is not as simple as unlocking the door when someone says s/he wants to leave. At the very least, you would follow the attending physician's orders/direction unless you were personally aware that that direction was a violation of state law and, even in that case, you would go up your own "chain of command," you wouldn't just open the door and let someone go unilaterally.

What is your job in the facility, and how long have you been working in psych?

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Specializes in Psych ICU, addictions.

Look at it this way: if a medically stable med-surg patient decided at 0300 that they wanted to leave the hospital, would you open the door and let them go right then and there? Probably not, right? I'd bet you'd make them wait to see the doctor in the morning. So why should it be any different in psych?

The MD (or DO, etc.) admitted them, and therefore the MD has to be the one to discharge them. The MD has to make sure that the patient is safe to leave the facility--just because they signed in voluntarily doesn't mean they are safe to be discharged. The discharge could wait until the morning when they've had a chance to assess the patient, or it could be a set of discharge orders phoned in. This means the voluntary patient may have to wait the night before they can get out...but the MD has to be the one to do it.

As far as holds expiring in the middle of the night, providers are usually aware of when patient holds expire and think ahead. If they're planning to place the patient on a 5250, they'll write the paperwork that day so it will be effective the second the 5150 expires. Same thing for the 5270.

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Look at it this way: if a medically stable med-surg patient decided at 0300 that they wanted to leave the hospital, would you open the door and let them go right then and there? Probably not, right? I'd bet you'd make them wait to see the doctor in the morning. So why should it be any different in psych?

The MD (or DO, etc.) admitted them, and therefore the MD has to be the one to discharge them. The MD has to make sure that the patient is safe to leave the facility--just because they signed in voluntarily doesn't mean they are safe to be discharged. The discharge could wait until the morning when they've had a chance to assess the patient, or it could be a set of discharge orders phoned in. This means the voluntary patient may have to wait the night before they can get out...but the MD has to be the one to do it.

As far as holds expiring in the middle of the night, providers are usually aware of when patient holds expire and think ahead. If they're planning to place the patient on a 5250, they'll write the paperwork that day so it will be effective the second the 5150 expires. Same thing for the 5270.

if I want to leave in the middle of the noc, who are you to say that I can not? facilitate, heck no. but get out of the way, I am leaving.

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Specializes in Nephrology, Cardiology, ER, ICU.

Moved to Psych nursing

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Specializes in Critical Care.

The laws are apparently quite different in my state compared to elkpark's. In my state a physician may request evaluation for a 72 hour hold for an voluntary admit wanting to leave, at which point the patient may be held for 4 hours while awaiting a DMHP evaluation, if the DMHP doesn't place a 72 hour hold on the patient before those 4 hours are up, then the patient can't be legally held.

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Specializes in Critical Care.
Look at it this way: if a medically stable med-surg patient decided at 0300 that they wanted to leave the hospital, would you open the door and let them go right then and there? Probably not, right? I'd bet you'd make them wait to see the doctor in the morning. So why should it be any different in psych?

The MD (or DO, etc.) admitted them, and therefore the MD has to be the one to discharge them. The MD has to make sure that the patient is safe to leave the facility--just because they signed in voluntarily doesn't mean they are safe to be discharged. The discharge could wait until the morning when they've had a chance to assess the patient, or it could be a set of discharge orders phoned in. This means the voluntary patient may have to wait the night before they can get out...but the MD has to be the one to do it.

As far as holds expiring in the middle of the night, providers are usually aware of when patient holds expire and think ahead. If they're planning to place the patient on a 5250, they'll write the paperwork that day so it will be effective the second the 5150 expires. Same thing for the 5270.

Of course you would let them go, unless you can establish that the patient isn't capable of making medical decisions, holding them against their will constitutes at least a misdemeanor and in some cases a felony.

The situation you describe is very similar to what required my current facility to enact a state-required remediation plan, it's also what got an RN and two staff members charged with crimes, which were eventually dropped.

You either have a legally valid basis for holding a patient, or you don't. Patient's are not required to submit to the medically (or nursing) recommended discharge process, that's what "against medical advice" means.

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Specializes in Psych ICU, addictions.
if I want to leave in the middle of the noc, who are you to say that I can not? facilitate, heck no. but get out of the way, I am leaving.

Sure, you could AWOL--I didn't say you couldn't. But why would the discharge process be any different whether it's med-surg or psych?

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