Involuntary hold guidelines

vintagemother, BSN, CNA, LVN, RN · Feb 28, 2015

Our clients are brought to the facility with holds already in place. There are only 2 reasons for "holds" dangerous to others or dangerous to themselves. eg homicidal or suicidal statements or actions.

We chart any observation or assessment of these behaviors.

We do have one other type of "hold". That is when the person is so "gravely disabled" by their mental illness that they can not take care of themselves.

As a facility, we do not make the determination of these, though we have input. Rather, a judge and law enforcement and often a public guardian makes these decisions. The clients receive a free public defender to assist with their defense.

MrChicagoRN, RN · Feb 28, 2015

Danger to self or others, or unable to maintain one's safety needs.

they can be brought in on a petition that is an observer's attest action of behaviors of concern, brought in by police, or self-present. A qualified examiner does the certificate which allows them to be admitted. If they don't sign in within 3 business days, we file court papers. Free attorney sees them before going to court.

elkpark · Mar 1, 2015

It's not a matter of what the policy is in anyone's facility, it's a matter of state law. The state laws specifying the grounds for involuntary commitment vary (somewhat) from state to state. The basic, generic standard is "acutely dangerous to self or others" but that gets interpreted a little differently in various states, and the length of time varies somewhat from state to state. Some states define "dangerous" to include unable to care for oneself. Some states include. In my current state, it doesn't matter how dangerous you are to yourself or others if the reason why is acute intoxication rather than mental illness, drugs and alcohol are specifically excluded from the involuntary commitment law. "Acute" is also defined differently in different states.

OP, from your user name, I'm going to guess you may be in PA. I'm now in PA. This is the fifth state in which I've practiced in my career, and I never imagined there could be an involuntary commitment system as Byzantine and Kafkaesque as the PA system. It's mind-boggling. Not only is the basic system incredibly complicated, but the fact that the system operates on a county-by-county basis means that there are significant differences in how the system functions in different counties in the state.

Meriwhen, ASN, BSN, MSN, RN · Mar 1, 2015

The legislation regarding involuntary holds varies between states.

California: the 72-hour hold is called a 5150 hold. It is for danger to self, danger to others, and/or grave disability. For the first two, a hold can be placed if the actions of and/or the statements made by the patient demonstrate a potentially serious intent to harm themselves or others. For the grave disability, the patient is unable to demonstrate that they can provide for their basic needs. There's no set statement that means an automatic hold: the patient and the whole situation needs to be assessed.

A patient who comes in on a 5150 can be held for up to 72 hours. While police, doctors, nurses, etc., can set a hold, only a psychiatrist can terminate it (end it) before 72 hours are up, or even not uphold it (they felt it shouldn't have been initiated in the first place). After 72 hours, the patient is free to go, unless....

The 5250 is a 14 day hold that follows on the 72 hour hold. Basically, the patient is still unsafe/unstable and needs further treatment. The psychiatrist initiates this before the 72 hour hold ends, and a hearing has to be held within a few days to determine if the hold will continue.

There are additional holds after this, but they are for those who are gravely disabled. There are also conservatorships that go from from 30 days up to forever, though they have to be renewed annually.

Also, a patient on a involuntary isn't automatically forced to take medication--they can refuse it. The only way medications can be forced is by court order (e.g., Riese, conservatorship) which is a procedure separate from the involuntary hold, or as an emergency psychiatric medication if the patient is an imminent danger to himself and/or others.

302queenpa · Mar 1, 2015

Exactly my point in asking lol. It is crazy how it works here. I work in 2 facilities in 2 county's and the procedures are so different.

Meriwhen, ASN, BSN, MSN, RN · Mar 1, 2015

I know the feeling. I bounce between three sites--two of with are part of the same hospital organization. All three sites are considerably different in how they do things. But even though the procedures vary between the facilities, the legislation should still be the same. IMO I don't think there's a lot of variation between the laws of each county. Still, it is something to double-check because I could very well be mistaken.

elkpark · Mar 1, 2015

I know the feeling. I bounce between three sites--two of with are part of the same hospital organization. All three sites are considerably different in how they do things. But even though the procedures vary between the facilities, the legislation should still be the same. IMO I don't think there's a lot of variation between the laws of each county. Still, it is something to double-check because I could very well be mistaken.

The issue in PA is that the law is state-wide, but how it gets interpreted and implemented varies (in some cases, significantly) from county to county. It's really bizarre (to me, anyway -- as I said, this is the fifth state in which I've practiced in my career, and I never imagined there could be such a bizarre involuntary commitment system/process).

302queenpa · Mar 1, 2015

Mind if i ask what part of pa your from elkpark? I work in Philadelphia and in one surronding county facility

elkpark · Mar 2, 2015

I'm in "the 'burgh."

302queenpa · Mar 2, 2015

cool always wanted to visit there

verene, MSN · Mar 3, 2015

The facility I work in is residential, and in the year I've been there the only time we sought authorization to send a resident out on involuntary hold was for grave disability. If this individual did not receive medical treatment death would be imminent (likely less than 7 days) and the individual was refusing all treatment with complete lack of understanding of how serious the medical condition was. (If the individual understood the severity and refused treatment we would have allowed the refusal and not sought the hold).

The other circumstances under which we might seek authorization for an involuntary hold would be suicidal or homicidal threats - in which case the threats must be clear and the individual not consenting to voluntary treatment.