Violations of Mental Health Act

[AnonymousCanadian]

Patients admitted and not informed of rights, patients admitted for involuntary assessment and not informed when they become voluntary, patients informed they are involuntary long after the law says they cannot be so (more than 72 hours), patients admitted as voluntary to locked unit ie not allowed to leave without doctors order. If this happened on your unit, with the implied consent of unit leadership, what would you do? I believe my role is to inform patients of their status and rights and to assist patients and advocate for their rights. I have spoken to doctors and they have ignored my concerns. So where to next? PS: I am Canadian, so much US regulation does not apply

[RochesterRN-BSN, BSN, RN]

Most patients can't reconstitute from a total decompensation within 72 hours.....this is not realistic for most. We have the option to admit to the EOB for a stay up to 72 hours or full admit. If they could reconstitute in 72 they wouldn't have been fully admitted. I am guessing you work for the legal side of things and don't know much about the realities of what a hospital stay is really like. Doctors do not keep patients that they feel can be safe if d/c'd--their license is on the line if they let someone go who is not stable and that person goes and has a successful suicide or homicidal event. If they are there they need to be there--they are sick and unsafe. The doctors do take letters from patients who feel they should be let go after 72 hours and it is there choice to write this letter or not--they are given a copy of their rights and status and the phone number for the NYS legal hygiene service in both hospitals I have worked at.....

[Meraki]

I'm in Ontario - so can only say based on that MHA. If admitted on a Form 1 - patients must be given a Form 42 informing them of the fact they are being held involuntarily. Otherwise the Form 1 is invalid and you are pretty much committing a crime - holding people against their will. There is no paperwork that needs to be done when the Form 1 (72 hr hold) expires if the person is becoming voluntary. They simply are then a voluntary patient. Patients can be kept involuntary for much longer than 72 hrs - that is what Form 3's and 4's are. Before the Form 1 expires or at any time the patient can be placed on a longer involuntary hold. If they are placed on a Form 3 or Form 4 then they have to have rights advice given to them by the PPAO. On my unit as nurses we take care of all the calling and informing for the most part - you can certainly tell a patient they are now voluntary or that they are involuntary - you can call PPAO on their behalf. If you are being asked to do something illegal - i.e. holding a voluntary patient who is at no imminant risk or holding patients against their will then call the college of nurses and get legal advice. You might want to try sitting down with your clinical manager or director and asking them to explain to you the unit policies from their perspective regarding MHA - maybe there is some miscommunication going on - i.e. docs are telling patients these things in sessions that you aren't aware of. The paperwork should all be on the chart though...if that doesn't work - you probably have a VP of nursing or a Director of nursing practice or someone who can give you additional advice. You may also have a patient advocate rep at your hospital who you could speak to in order to find out how to provide the best patient care.

[Mr Ian]

Patient's have an implicit right to this information. You are right to raise concern.

However, the doctors are not liely to help as it presents a huge conflict of interest. This doesn't mean they don't agree with you - but they would make a huge rod for their own backs sometimes (as per PsychRNinNY comments).

MHA law is an administrative law and as such ought have monitoring and checking devices/processes built in.

Mental Health Review Tribunal is most common one I know of (UK & Australia) who review the clinical necessity for regulation under an Act; Mental Health Act Commission (UK) review the processes and verify that health facilities are in compliance with the Act requirements. Locally we've just instilled a minor checking device on out Intake Process to assure all new referrals are advised of the MHA. We also have a MHA Administration who monitor the compliance of the legal side - things like detention and seclusion etc.

I would review your local MH Act and see what provisions are in there for monitoring and checking.

Patients should have access to legal advice and their representative should check on these things - unfortunately most MH legal advisors/solicitors/lawyers aren't that good or knowledgesd about MHA provisions and do it as a side-line.

Independent Advocacy is the other alternative - but they need to be aware of the problems and how the Act is being compromised before they can address it.

[AnonymousCanadian]

I'm in Ontario - so can only say based on that MHA. If admitted on a Form 1 - patients must be given a Form 42 informing them of the fact they are being held involuntarily. Otherwise the Form 1 is invalid and you are pretty much committing a crime - holding people against their will. There is no paperwork that needs to be done when the Form 1 (72 hr hold) expires if the person is becoming voluntary. They simply are then a voluntary patient. Patients can be kept involuntary for much longer than 72 hrs - that is what Form 3's and 4's are. Before the Form 1 expires or at any time the patient can be placed on a longer involuntary hold. If they are placed on a Form 3 or Form 4 then they have to have rights advice given to them by the PPAO. On my unit as nurses we take care of all the calling and informing for the most part - you can certainly tell a patient they are now voluntary or that they are involuntary - you can call PPAO on their behalf. If you are being asked to do something illegal - i.e. holding a voluntary patient who is at no imminant risk or holding patients against their will then call the college of nurses and get legal advice. You might want to try sitting down with your clinical manager or director and asking them to explain to you the unit policies from their perspective regarding MHA - maybe there is some miscommunication going on - i.e. docs are telling patients these things in sessions that you aren't aware of. The paperwork should all be on the chart though...if that doesn't work - you probably have a VP of nursing or a Director of nursing practice or someone who can give you additional advice. You may also have a patient advocate rep at your hospital who you could speak to in order to find out how to provide the best patient care.

Leadership is not receptive to this kind of communication. It is a "do as I say" situation, which staff acquiesce to for whatever reason (we need jobs?) We don't have the same level of documentation here so papertrails are poor or virtually non-existent in some cases. You mention pt being involuntary at the end of the 72 hr obs period. Where I work, the 72 hr period is extended without documentation for "completing the assessment." And in some cases when pts come for 72 hr obs and are found not certifiable but in need of hospitalization, they are simply not informed of their status. This is not on my initiative, this is by direction. I find among some co-workers there is what I characterize as an attempt at "plausible deniability." It's difficult to swallow. I have tried without success to educate staff, and now I don't involve myself with the handling of these pt situations. It's discouraging and I'm out of energy. There is so much effort put into excellence in nursing care, and at the same time such a disingenuous attempt at dealing with involuntary assessments, it's making me crazy!

[AnonymousCanadian]

What is it, 6 months later?...and more of the same....