illegal use of QR???

Specialties Psychiatric

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Just a question ( i dont work in pscyhe anymore). I used to work in a child/adolescent psyche unit. The kids were VERY often placed in the quiet room for behavioral types issues, like talking back or cursing, but NOT necessarily for violent behaviors. Our policy stated that the QR was only to be used (by MD order) for a patient that was putting him or herself or others at risk for danger (cant remember the exact wording). Of course, it was hush hush and not to be documented as it was abused. Even the MANAGER of the unit allowed it - I never understood this! Isn't this totally illegal and unethical? It just never sat right with me, along with other things on this particular unit. Does this happen a lot? Is this a common thing? Seemed so wrong to me....still bugs me. Any feedback???

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Well, I'm fairly new to psych, but we also use the QR (soon to be called the Comfort Room instead) for foul language and such. I do not think that is abusing the QR. When a patient is disruptive to the milieu, even if he or she is not in imminent danger of violence, we have to seperate the patient from the other. It's not fair to the other children who are supposed to be getting help, to subject them to disruption by another patient. The disruptive patient leeches staff availibility and attention from the others. In addition, that kind of behaviour sometimes snowballs, and other kids feed off of it. Pretty soon, you are out-numbered by kids who are teetering dangerously close to a 'mob mentality', where their decision making skills are muted by having a degree of anonymity within the group. (The old 'everyone was doing it' thing). It's just my opinion, but for the comfort and saftey of all, I don't think it is inapporpriate to have a pt in the quiet room for bad language, and the other stuff you mentioned. UNLESS the staff is keeping them in there for hours on end.

One thing I do NOT agree with, however, is that when our floor is full, sometimes they will 'make' an extra bed by having someone sleep in the quiet room. Not as a consequence---but simply to make room.

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Are we talking about asking a kid to take a (voluntary) time out to calm down and get it together, in an unlocked "quiet room"? Is the child free to leave the room, or is staff preventing that by either locking the door or physically preventing the kid from leaving (standing in the doorway)?

Asking/encouraging a child to take a voluntary time out in a less-stimulating setting is fine. However, if the door is locked or staff in any other way are preventing the child (or adult, the rules are the same) from leaving the room, that is seclusion, according to the CMS (Federal) rules under which your hospital is required (has voluntarily agreed) to operate, and, probably, your state rules, too -- you'd better be following all the rules about doctors' orders, face-to-face evaluation, documentation, etc., for every episode, regardless of how brief the episode is. As far as the Feds are concerned (and, probably, your state, too), seclusion is seclusion, whether it's five minutes or five hours.

I've been a psych nurse for >20 years, and am well aware of how difficult and challenging the newer rules make it to operate a psych unit (esp. with kids, which is my specialty), but the rules were developed in response to abuses of the past (abuses which are still going on, as we can see from this thread). I have also worked for the last several years as a psych surveyor for my state and the Feds, and can tell you that you do not want to get in trouble with CMS about this stuff -- they take it v. seriously.

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Specializes in Psych, Med/Surg, LTC.
Well, I'm fairly new to psych, but we also use the QR (soon to be called the Comfort Room instead) for foul language and such. I do not think that is abusing the QR. When a patient is disruptive to the milieu, even if he or she is not in imminent danger of violence, we have to seperate the patient from the other. It's not fair to the other children who are supposed to be getting help, to subject them to disruption by another patient. The disruptive patient leeches staff availibility and attention from the others. In addition, that kind of behaviour sometimes snowballs, and other kids feed off of it. Pretty soon, you are out-numbered by kids who are teetering dangerously close to a 'mob mentality', where their decision making skills are muted by having a degree of anonymity within the group. (The old 'everyone was doing it' thing). It's just my opinion, but for the comfort and saftey of all, I don't think it is inapporpriate to have a pt in the quiet room for bad language, and the other stuff you mentioned. UNLESS the staff is keeping them in there for hours on end.

One thing I do NOT agree with, however, is that when our floor is full, sometimes they will 'make' an extra bed by having someone sleep in the quiet room. Not as a consequence---but simply to make room.

I noticed the snow ball effect as well when I worked child psych. We tried to only put those that were at rish of injury to themselves or others in the QR. Those who were very disruptive or using foul lang. got sent to their rooms or had to stay in the hallway outside of the day room. We also sometimes had a pt sleep on a matt in the QR to make an extra bed (usually the most violent kid that ends up in there the most anyway) but that isn't fair to that kid. They feel like they are being punished. It also causes a problem when you have a kid flipping out at 3am and need to use the QR and there is a child already sleeping in there. Then we have to carry them to the adolescent unit (adjacent) and "borrow" their QR.

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I noticed the snow ball effect as well when I worked child psych. We tried to only put those that were at rish of injury to themselves or others in the QR. Those who were very disruptive or using foul lang. got sent to their rooms or had to stay in the hallway outside of the day room. We also sometimes had a pt sleep on a matt in the QR to make an extra bed (usually the most violent kid that ends up in there the most anyway) but that isn't fair to that kid. They feel like they are being punished. It also causes a problem when you have a kid flipping out at 3am and need to use the QR and there is a child already sleeping in there. Then we have to carry them to the adolescent unit (adjacent) and "borrow" their QR.

You are right, I forgot to mention that sending them to their room is an alternative to the QR. It is when they are still carrying on in their room, punching walls, ect that they go to the QR.

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The kind of quasi legal use of quiet room is an indicator that the adolescent program in question is out of control. You are bending the rules to make things work. This is not safe and is very likely to lead to serious trouble down the road. No one will see anything wrong with your pactices as long as no one gets hurt but when someone does it willbe you who were the licensed personel who were not following proceedure.

If you insist on obeying the rules and/or writing up the situation when they are not obeyed you can force change. A word of caution: It may be that the only way change is possible will be the collapse of the institution. This has happened to my local state hospital.

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The kind of quasi legal use of quiet room is an indicator that the adolescent program in question is out of control. You are bending the rules to make things work. This is not safe and is very likely to lead to serious trouble down the road. No one will see anything wrong with your pactices as long as no one gets hurt but when someone does it willbe you who were the licensed personel who were not following proceedure.

If you insist on obeying the rules and/or writing up the situation when they are not obeyed you can force change. A word of caution: It may be that the only way change is possible will be the collapse of the institution. This has happened to my local state hospital.

I completely agree.

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