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Holding voluntary patients - illegally?

Psychiatric   (3,447 Views 61 Comments)
by SoCal student SoCal student (Member)

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Duranie works as a Homemaker, currently.

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As far as I can find, this is the State of Nevada statute regarding a voluntary mental health admit that wants to leave, as with many of these statutes it's as clear as mud:

There are at least three different ways of reading that. One is that if the request to be released is made during the "normal working day" then they must be "immediately released", another is that they must be released in the same "normal working day" in which the request was made, although the 24 hour window for changing their status to non-voluntary / "emergency" makes that confusing.

 

Just based on the basic rules of grammar, it seems to say the patient must be released immediately if their request is made within the normal working day. To read it as allowing the patient to be released later in the day would require an additional comma that isn't in the statute.

You're right, Muno, that statute is as clear as Mississippi mud....

 

It obviously can't be both ways-- either a provider/facility has 24 hrs after the pt. asks to leave to determine whether a patient's status meets the criteria for involuntary hold, or they don't....

 

The courts (at least in the US) have generally held that if there is ambiguity in the way a law can be interpreted, it should be construed in such a way that there is the least restriction to a citizen's liberties. *

So, in this case, I would take it to mean a pt. needs to be released "immediately" and if, upon review in the subsequent 24 hours, it's decided that there was cause to hold the patient involuntarily after all, then I guess police would have to be sent to try to find the pt. and bring them back in.

Talk about closing the barn door after the horse is out?... :sarcastic:

 

OP, perhaps you could contact risk management to ask them to explain your facility's policy, and how it jives with state law. (if you get an answer from them, I would make sure to send a follow-up email to whomever you speak with in RM thanking them for their help in understanding the policy, and confirming/summarizing the answer you were given .... cc yourself on that email--and send it to a non-work acct. It's the only way you'll be able to CYA if the policy is ever called into question later... because I guarantee, if ever the feces contact the proverbial air propeller, no one in RM will remember having proffered an opinion.)

If you don't get a satisfactory answer, try calling the ombudsman at the Nevada Division of Public and Behavioral Health to ask them for guidance.

Good luck. I think it's great that you want to have as much info as you can in order to effectively advocate for the rights of the patients in your care....

*N.B. A very good article about individual liberties --food for thought re: personal freedoms that can be extrapolated to patient rights.

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Would you mind pointing me precisely to your state's law that cites this?

If you can't, you're pretty much in the same boat as me.

Psych nurses, at least in my state (the sample of co-workers I've asked - the only ones I have asked before asking here), do not know the answer to this. They understand how a legal hold works. They understand how an AMA works. No one has been able to point me specifically to the state law that outlines the patient's rights in this situation.

So I guess that makes me what? Neglectful? Ignorant? Sounds more like the confusion and lack of an easy, straight-forward answer is more a systemic issue than an individual one (me, being a psych nurse of 6 years that "doesn't understand this.").

I've already explained the process in the state in which I've spent the majority of my career, and the state in which I've been living and practicing for the last several years, so, obviously, I am familiar with the requirements (as I have made sure to be throughout my career, wherever I've been practicing. This is stuff you just have to know as a psychiatric nurse). However, I just found the specific legislation for both states, and it took about three minutes on line:

Chapter 122C - Article 5

§ 122C-212. Discharges.

(a) Except as provided in subsections (b) and © of this section, an individual who has been voluntarily admitted to a facility shall be discharged upon his own request. A request for discharge from a 24-hour facility shall be in writing.

(b) An individual who has been voluntarily admitted to a 24-hour facility may be held for 72 hours after his written application for discharge is submitted.

https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwjz7qymgujeAhWD1FkKHTYJCY8QFjAAegQIChAC&url=https%3A%2F%2Fwww.pitt.edu%2F~kconover%2Fftp%2F302-text.pdf&usg=AOvVaw08YjbBqY9fD1TMyU8fS9gX

7206. Withdrawal from voluntary inpatient treatment (a) A person in voluntary inpatient treatment may withdraw at any time by giving written notice unless, as stated in section 203, he has agreed in writing at the time of his admission that his release can be delayed following such notice for a period to be specified in its agreement, provided that such period shall not exceed 72 hours. Any patient converted from involuntary treatment ordered pursuant to either section 304 or 305 to voluntary treatment status shall agree to remain in treatment for 72 hours after having given written notice of his intent to withdraw from treatment.

(Please note that, while the PA statute states that the individual must be released "at any time" unless s/he has "agreed in writing at the time of his admission that his release can be delayed following such notice for a period to be specified in its agreement, provided that such period shall not exceed 72 hours," the official state voluntary admission consent form which is used consistently throughout PA for voluntary psychiatric admissions has the 72-hour thing written into it -- so every individual being voluntarily admitted to an inpatient psychiatric setting has "agreed in writing" to the additional 72-hour hold after they request discharge.)

Edited by elkpark

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bgxyrnf has 10 years experience.

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I never said they were prisoners. I just didn't know if there were any differences in how these things worked in a non-psychiatric setting. It may seem a silly question to you, but remember that 98% of my nursing has been in psych settings. I'm used to working in the "it's a whole other ballgame" world.

And I've learned that essentially, there's not really that much difference.

You made no assertion at all... you simply asked an honest question, and not a silly one at all.

My 'patient not prisoner' remark is a deliberately blunt attempt to emphasize their autonomy and complete right to self-determination.

My apologies if it seemed that I was wrongly assigning a belief to you... or if the comment came off as snarky.

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bgxyrnf has 10 years experience.

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Sure, you could find me liable. But, if you're a patient that was falsely imprisoned and you're suing for damages, do you go after the RN or the hospital that enacted policies that, when followed by staff, resulted in the false imprisonment.

If I were your patient and you refused to unlock that door, I'd certainly come after you in addition to your employers because you would be the one who had denied me my civil liberties.

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44 Likes; 2 Followers; 102,768 Visitors; 14,620 Posts

If I were your patient and you refused to unlock that door, I'd certainly come after you in addition to your employers because you would be the one who had denied me my civil liberties.

In an acute medical setting, sure (although probably a moot point, since there are rarely locked doors). In an inpatient psychiatric setting, you're unlikely to get anywhere legally if the providers are following the process prescribed by state law.

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1 Like; 2,372 Visitors; 48 Posts

I've already explained the process in the state in which I've spent the majority of my career, and the state in which I've been living and practicing for the last several years, so, obviously, I am familiar with the requirements (as I have made sure to be throughout my career, wherever I've been practicing. This is stuff you just have to know as a psychiatric nurse).

I already explained the requirements and process for initiating, certifying, implementing a legal hold in my state. I have also already explained how voluntary admissions and discharges work in my state (at least in the facilities I have worked in). So, obviously, I am familiar with the requirements. This knowledge has served me well for 6 years. Yet, I'm curious as to the legality of a hypothetical situation that has yet to present itself to me.

I appreciate your insight but I have to fundamentally disagree with your (and a couple other members') apparent assertions that nurses that do not understand 100% of laws and regulations are somehow ignorant/negligent/irresponsible.

As I've states numerous times: this is a hypothetical situation - I've 100% been able to de-escalate/reason with/work with voluntary patients requesting AMA over 6 years. So, should I be constantly scouring my state's laws based on hypotheticals I come up with in my head, just in case? Do you really thing nurses do/should do this?

Nurses should undoubtedly be aware of their Nurse Practice Act and should have some limited knowledge of their state's statutes. To expect nurses to have an in-depth, nearly all-encompassing understanding of the law is unreasonable.

I remember learning in school (and am reminded at every JACHO audit) that nurses don't need to know the answers to everything. They do need to know when to seek the answer elsewhere.

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You're right, Muno, that statute is as clear as Mississippi mud....

 

It obviously can't be both ways-- either a provider/facility has 24 hrs after the pt. asks to leave to determine whether a patient's status meets the criteria for involuntary hold, or they don't....

 

The courts (at least in the US) have generally held that if there is ambiguity in the way a law can be interpreted, it should be construed in such a way that there is the least restriction to a citizen's liberties. *

So, in this case, I would take it to mean a pt. needs to be released "immediately" and if, upon review in the subsequent 24 hours, it's decided that there was cause to hold the patient involuntarily after all, then I guess police would have to be sent to try to find the pt. and bring them back in.

Talk about closing the barn door after the horse is out?... :sarcastic:

 

OP, perhaps you could contact risk management to ask them to explain your facility's policy, and how it jives with state law. (if you get an answer from them, I would make sure to send a follow-up email to whomever you speak with in RM thanking them for their help in understanding the policy, and confirming/summarizing the answer you were given .... cc yourself on that email--and send it to a non-work acct. It's the only way you'll be able to CYA if the policy is ever called into question later... because I guarantee, if ever the feces contact the proverbial air propeller, no one in RM will remember having proffered an opinion.)

If you don't get a satisfactory answer, try calling the ombudsman at the Nevada Division of Public and Behavioral Health to ask them for guidance.

Good luck. I think it's great that you want to have as much info as you can in order to effectively advocate for the rights of the patients in your care....

*N.B. A very good article about individual liberties --food for thought re: personal freedoms that can be extrapolated to patient rights.

Thanks for weighing in.

As to your last point: I truly appreciate you noting that. I've come here with this question after being dissatisfied with my coworkers' approaches towards this issue (basically, "Well our facilities policy is..."). They seem completely oblivious to the fact that private companies cannot override civil rights.

I've got a lot of responses from well-meaning people here. But, I'm equally dissatisfied by the response of, "How you do you not know this? You should know this by now." As previously stated, this is a hypothetical that I have yet to encounter. I've been able to avoid this situation with 100% of voluntary AMAs I've encountered in the last 6 years. I can almost guarantee I could finish the rest of my nursing career in my state without knowing this answer.

But, if I want to be able to advocate more for my patients than my facility, it would be great to know.

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Meriwhen is a ASN, BSN, RN and works as a Psychiatric sheep...er, nurse.

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You made no assertion at all... you simply asked an honest question, and not a silly one at all.

My 'patient not prisoner' remark is a deliberately blunt attempt to emphasize their autonomy and complete right to self-determination.

My apologies if it seemed that I was wrongly assigning a belief to you... or if the comment came off as snarky.

No offense was ever taken, no worries :)

But it was kind of surreal because after years of answering questions from non-psych nurses about how things work in psych--and you'd be surprised (or probably not) at how many non-psych nurses do have a "prisoners"-ish mentality about psych patients--here I am asking about how some of the things work on the non-psych side.

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233 Likes; 1 Follower; 13,027 Visitors; 1,360 Posts

Thanks for weighing in.

As to your last point: I truly appreciate you noting that. I've come here with this question after being dissatisfied with my coworkers' approaches towards this issue (basically, "Well our facilities policy is..."). They seem completely oblivious to the fact that private companies cannot override civil rights.

I've got a lot of responses from well-meaning people here. But, I'm equally dissatisfied by the response of, "How you do you not know this? You should know this by now." As previously stated, this is a hypothetical that I have yet to encounter. I've been able to avoid this situation with 100% of voluntary AMAs I've encountered in the last 6 years. I can almost guarantee I could finish the rest of my nursing career in my state without knowing this answer.

But, if I want to be able to advocate more for my patients than my facility, it would be great to know.

It sounds like your question is: "Is a legal hold illegal?" The answer is no.

Things that are legal for a particular set of circumstances cannot also be illegal for the exact same set of circumstances.

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hppygr8ful has 15 years experience and works as a RN - Adolescent Psych.

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I've searched the Nevada statutes and could not find an answer. I haven't asked everyone in my facility as I'm not keen on being marked as anything (even if for a valid reason). I have asked a number of people and, no, they do not know the answer. Figured I'd ask here first before going to the nursing board, dept. of mental health, etc.

Yes, I've worked as a psych nurse both privately and publicly in NV for 6 years. Why don't I know the answer? Ninety-nine percent of my admissions have gone along with the process rather easily. There have been a few instances that escalated to the point of calling a house sup/doc/admin immediately and those patients were discharged quickly. Still, that didn't answer my question of whether we were, up until that point (after the pt. requested AMA), falsely imprisoning them.

Knowing the legal requirements, etc. is important. I agree. In this case, I would assume with false imprisonment being both a tort and a felony, that the law would be fairly identical or at least extremely similar across the entire country.

I am very well-versed in our state's process of initiating a legal hold, certifying it, petitioning patients for court, etc. Most nurses in my facility come to me when they have questions regarding this process. But let's not act like every nurse knows every law. This particular, nuanced question was apparently never important enough to be taught in nursing school (in NV), at various orientations/in-services, etc.

Not a big fan of being accused of some sort of negligence for seeking out the answer to a question that no one seems to know the answer to.

Again, I assume a patient would have every claim to false imprisonment in the same circumstance nationwide. Given that, why can't anyone here answer completely in the affirmative? Maybe because there is confusion and we're nurses, not lawyers.

In NV, various people can initiate a legal hold (LSW, RN, MD, police officer) and it then must be certified by a psychiatrist or psychologist. I've initiated many legal holds.

We do the same as well - try everything we can to talk a patient into staying - which usually works.

I totally agree with you. Especially if you get a particularly litigious patient. I'm not touching them until I need to. But I'm also at this point not unlocking the doors. I can't imagine a jury would ever find me liable for not opening the doors in this case. I think they'd find issues with the hospital's policies and training.

Still, I'd love to have the law on my side and be able to justify any of my actions in real time.

Unless you work in a completely involuntary, locked facility, I don't think there's a difference - that's my point. I would think a voluntary patient in my hospital would have every single right (in terms of AMA) that a voluntary patient in a medical setting would. The only difference is the doors are locked. So they can't just walk out. My hunch is any lawyer worth their salt could easily make a false imprisonment claim if such a patient was not allowed to walk out of a facility for any significant amount of time.

You say you've spent a great deal of time researching this yet in just a couple of minutes I found this power point that explains the law regarding psych detainment. According to Nevada law addiction, detox, and intoxicated patients are not deemed to be mentally ill so they cannot be held in the hospital against their will. Does your facility not have a risk manager who would know this information and your facilities policy.

Hppy

http://dpbh.nv.gov/uploadedFiles/dpbhnvgov/content/Boards/RBHPB/Meetings/2018/Legal%202000%20Process.pdf

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That power point states very basic information that I've been well aware of for years.

You're kind of missing the point again. I'm not talking about holding them for any extended period of time against their will. I'm talking about opening the locked doors to the facility immediately, before having a doctor's order, discharge plan, etc.

My facility's policy is clear. We don't open locked doors until those requirements are met. Company policies don't supercede civil rights.

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233 Likes; 1 Follower; 13,027 Visitors; 1,360 Posts

That power point states very basic information that I've been well aware of for years.

You're kind of missing the point again. I'm not talking about holding them for any extended period of time against their will. I'm talking about opening the locked doors to the facility immediately, before having a doctor's order, discharge plan, etc.

My facility's policy is clear. We don't open locked doors until those requirements are met. Company policies don't supercede civil rights.

Okay. You should have just stated whether or not these are psych voluntary patients from the beginning. If you still aren't sure then you need clarification on that too.

Philosophically speaking, If none of your patients are ever psych voluntary then your unit should not be locked. Pts in detox who are hallucinating would get a 1 to 1 or some kind of special precaution to prevent harm.

Again, philosophically speaking, you are imposing a restraint/imprisonment when you refuse to open the locked door. Maybe the law gives you a certain amount of time to reason with the patient. I don't know.

What is the maximum amount of time it would take you to get a discharge order or get a doc?

Did you call the legal department yet? Because that is where you need to start. If the policy is illegal, the legal dept is responsible for getting it changed.

Edited by FolksBtrippin

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