Holding voluntary patients - illegally?

[SoCal student]

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?

[SoCal student]

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?

I'm a psych RN of about 6 years. I've gone along with my facility's policies as I'm usually able to de-escalate a pt. and, once they've made enough noise, I can basically force a doc to see them and shift the onus to them.

My facility is a psychiatric/behavioral health hospital, but patients are either admitted as "psych" or "detox." While the detox patients are always voluntary (at least on admission - they may be placed on a legal hold of that becomes necessary), psych patients can be either voluntary or on a legal hold.

I ask because I work with many who blindly follow the facility's policies with no regard to what may actually be lawful. "Oh he can't AMA, it's passed 3pm." Ok, this guy is here voluntarily for detox only. Not suicidal, not homicidal, not psychotic, not unable to to care for self. Now he's calling his lawyer saying he's being held against his will. Are you willing to go to court and possibly let be held liable as "the policy says..."?

[SoCal student]

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 a medically and mentally stable patient stands up and begins walking out of their room/hospital, are you going to physically lay hands on them as they say "I don't care, I'm leaving against medical advice"?

[elkpark]

If a medically and mentally stable patient stands up and begins walking out of their room/hospital, are you going to physically lay hands on them as they say "I don't care, I'm leaving against medical advice"?

Well, in a locked psychiatric facility, it's kind of a moot point since the doors are locked. I'm going to attempt to intervene verbally, explain the legal process, and attempt to resolve the immediate situation peacefully. Am I going to open the door and let the person leave? No. I'm going to follow the state's legal process that governs these situations.

[Meriwhen, ASN, BSN, MSN, RN]

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.

I know that you can't force anyone to undergo medical treatment unless there's a court order. We regularly deal with patients who will take psych meds willingly but refuse the non-psych ones even if it's obvious that they need them. But back to the main topic...

I've done my fair share of AMAs and they've been after the patient has talked to the doctor or I called the MD for the order. But are you saying that a med-surg patient can just walk off the medical floor without any form of discharge order (either in person or given via phone) from the MD? Basically just elope? I wonder what the legal and financial (insurance) ramifications would be for that.

I'm not being facetious in asking--I've never worked on a medical floor. I've only consulted.

I can tell you (in my experience anyway) that 98% of the time, that medical staff is not going to drop everything to call the MD at 0300 when the med-surg patient says, "I want to go." No, they're going to do everything possible first to convince that patient to hold off on leaving until the patient can see the MD, especially in today's litigation-happy world. I know this because more than once I've been called over to that medical floor to do a consult to see if they have any case for placing the patient on any form of psych hold (answer: usually not). And while I'm there, I've also seen staff do a hard sell on the patient to get them to stay. It's not as though they're packing up the bags.

[elkpark]

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.

(Actually, in my experience, people leave inpatient medical settings AMA at all hours of the night on a regular basis, and no one "makes" them wait until morning. If there are no legal grounds to detain them and no concerns about capacity, we may attempt to persuade them to stay until morning, but they walk when they want to walk.)

[Meriwhen, ASN, BSN, MSN, RN]

(Actually, in my experience, people leave inpatient medical settings AMA at all hours of the night on a regular basis, and no one "makes" them wait until morning. If there are no legal grounds to detain them and no concerns about capacity, we may attempt to persuade them to stay until morning, but they walk when they want to walk.)

But would the MD be contacted for a discharge order via phone, or do they leave sans order?

[hppygr8ful, ASN, RN, EMT-I]

In California which is where I work a voluntary patient who requests AMA discharge from a psych facility must be assessed by a LPS designated staff within 1 hour of their asking to leave the hospital. Often times when the physician is notified he will authorize a routine discharge if the patient is medically stable and from a psychiatric standpoint does not meet criteria for being placed on a hold. If the Physician strongly feels that the patient is unsafe and the patient leaves AMA the hospital and physician must still provide a discharge plan, prescriptions and referral for follow-up care. It is illegal to tell a patient that he/she will be financially responsible as the Insurance company still has to pay for any used authorized days.

If the LPS staff finds during the assessment that the person is a danger to self, Danger to others or gravely disabled they will write a 72 hour hold so that the patient can be held in the hospital. The patient has a right to ask for a by-pass writ and appear in superior court within two business days. Of he/she can wait the 72 hours and if they are still considered DTS/DTO they can be held for up to 14 days. They will have a day in court so to speak within 2 business days and judge decides if they stay or go.

Hppy

[SoCal student]

Well, in a locked psychiatric facility, it's kind of a moot point since the doors are locked. I'm going to attempt to intervene verbally, explain the legal process, and attempt to resolve the immediate situation peacefully. Am I going to open the door and let the person leave? No. I'm going to follow the state's legal process that governs these situations.

Totally. And that is my ultimate question. What is the state's legal precedent?

Yea, my employer would fire me if I opened the doors. And it's very unlikely that a patient would come after me personally for liability if I followed policy and, went up the chain.

Still, I want to know my patients' rights within the law so I can effectively advocate for them. I'm sick of sycophants trying to skirt responsibilities and/or make more money for the admins by dismissing patients. If voluntary patients who just happen to be in a locked facility wish to leave AMA and, by law, have the right to be let out of the hospital immediately, I want to know that so I can advocate for them.

[SoCal student]

I've done my fair share of AMAs and they've been after the patient has talked to the doctor or I called the MD for the order. But are you saying that a med-surg patient can just walk off the medical floor without any form of discharge order (either in person or given via phone) from the MD? Basically just elope? I wonder what the legal and financial (insurance) ramifications would be for that.

Yes? I appreciate you weighing in and I'm not being facetious either.

Just as I'm trying to figure if a legal right exists for me to keep a patient against their will when they do not fit criteria for a legal hold, you would need to figure out if a legal right exists for you to (possibly?) falsely imprison them.

Again, if a patient is medically/mentally stable and does not meet criteria for a mental health hold, what is your response to them getting up and walking out of a non-locked facility? Tackle them? Restraints? That's crazy. Is someone going to sit on the witness stand and say "Well yea, we restrained him. Why? Because there wasn't a doctor's order for discharge."

[Duranie]

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.

Can anyone advise on this?

I think the bolded statement is what it ultimately comes down to....

If upon admission, a pt. signs consents that impose various conditions on treatment and/or discharge, then the pt. will be held to those conditions while there. Therefore, if one of the things they agree to is that AMA discharge will be requested in writing before a certain time, or have to wait until the next day to be processed, then why wouldn't the facility be within its rights to expect a pt. to go along with the restrictions that were spelled out from the beginning.

Now, if there was no prior notice given of the facilities policies, or if the pt. hadn't agreed to certain conditions on admission, then maybe they would have a legitimate complaint of being held against their will, or whatever.

Whether the facility is for-profit or not has no bearing in this matter, because it's simply a matter of what the patient agrees to at the time of admission.

If a lot of patients are confused by the delays @ AMA discharge, then perhaps there needs to be better explanation when the papers are being signed at the time of admission of the policies that the patient is/will be expected to comply with.

[elkpark]

Totally. And that is my ultimate question. What is the state's legal precedent?

Yea, my employer would fire me if I opened the doors. And it's very unlikely that a patient would come after me personally for liability if I followed policy and, went up the chain.

Still, I want to know my patients' rights within the law so I can effectively advocate for them. I'm sick of sycophants trying to skirt responsibilities and/or make more money for the admins by dismissing patients. If voluntary patients who just happen to be in a locked facility wish to leave AMA and, by law, have the right to be let out of the hospital immediately, I want to know that so I can advocate for them.

Since no one who's come along so far is familiar with the law in Nevada, none of us can answer that specific question for you. As I said earlier, if no one at your facility is familiar with the state rules/regs on this question (which I find hard to believe), the state department of mental health can advise you. Have you spent your six years working in psych in Nevada, specifically? If so, how is it you don't already know the answer? Is this the first time this question has come up in your career? Knowing the legal requirements of admission and discharge in psychiatric settings in the state in which you're practicing is important.

[elkpark]

But would the MD be contacted for a discharge order via phone, or do they leave sans order?

Of course the nurse would contact the physician. The individual would be seen ASAP by the physician if s/he is readily available, or the nurse would contact the physician by telephone and review the situation, just as you would contact the physician re: any significant change in the client's status or condition, and they would figure out what to do about the situation.