What would you do if you were making the decisions?

morte, LPN, LVN · Sep 13, 2009

i think you need to check the wording on the first one

PMHNP10 · Sep 13, 2009

oops, lol; unfortunately I cannot edit, so from hereforth, John is a female

so aside from the lack of editing on my part, do you have any responses to any of the scenarios?

Jules A, MSN · Sep 13, 2009

There really isn't much to do other than document what needs to be documented, pass along the information to the proper people, follow your facilities protocol for such infractions and continue to care for them in a therapeutic manner.

morte, LPN, LVN · Sep 13, 2009

I'd like to post a few vignettes of patients and ask what would you do if you were in charge of the program/unit involved (i.e., how would you handle the situation)? Please provide a rationale for your decision.
1) John, is participating in an outpatient substance abuse research program. As part of the program, she receives a voucher to be turned in to the business office for money as compensation for her participation in the study. One day, Mary decides to place an additional 0 at the end of the dollar amount. The business office notices this addition and calls the clinic to verify.
2) Billy, Jeff, Carl, and Darryl are adolescent patients in a residential substance abuse treatment program. They decide to bring assorted products back from the cafeteria (e.g., fruit, sugar, bread) and make their own alcohol. Staff, during a search find the fermenting concoction.
3) Jill, Mary, and Joe are patients in an inpatient psychiatric facility for depression. They decide to cheek their meds and at night crush them and snort them. Staff walk in on the trio while inhaling their crushed meds.
4) Matt and Nicole are adolescents in a residential substance abuse treatment program. One afternoon they are found in the laundry room having sexual intercourse.
5) Vince has been hospitalized in your inpatient psychiatric unit 3 times in the past 2 months. His story each time he presents to the ER is that he is depressed, suicidal with a plan to walk into traffic, and hearing voices that tell him to harm himself. He also reports using crack cocaine on a regular basis. At each discharge there is a plan established, but he does not follow through on his end, only saying that he can't. When he gets onto the unit, he becomes demanding for food and medications (pain meds and psychotropics that will knock him out), refuses to take a majority of his non-sleep inducing psychiatric medications, and is disruptive to the millieu.

well, i am not a psych nurse, but a few comments

1) mary just commited a crime...minimum she is out of the research project

2) potentially crime here, minors in possession....dont think that would be pushed, but i would think loss of privleges....

3) better supervision

4) unless these are emancipate minors (or adolescents over 18) this again raises legal issues, and the parents may need to be notified

5) he should no longer be welcome, if he is not doing......perhaps a "Rogers" order is in order?

PMHNP10 · Sep 13, 2009

thank you for your responses; overall I agree with you except I'd probably boot the frisky adolescent couple out of the program; word gets around in the mental health community and if the word is that you can hook up and the consequences aren't too severe, it invites trouble from future patients, and potentially brings a bad name/reputation to the program

on the other hand, since I stated this was an adolescent program, chances are that they don't want to be there, so perhaps this was, among other things, motivated by the desire to get out early; hmmmmm....I might have just changed my mind a little bit

what is a "'Rogers'"?

PMHNP10 · Sep 13, 2009

There really isn't much to do other than document what needs to be documented, pass along the information to the proper people, follow your facilities protocol for such infractions and continue to care for them in a therapeutic manner.

you are the "proper people"; congrats on the promotion; so what do you do with these folks?

morte, LPN, LVN · Sep 13, 2009

thank you for your responses; overall I agree with you except I'd probably boot the frisky adolescent couple out of the program; word gets around in the mental health community and if the word is that you can hook up and the consequences aren't too severe, it invites trouble from future patients, and potentially brings a bad name/reputation to the program
on the other hand, since I stated this was an adolescent program, chances are that they don't want to be there, so perhaps this was, among other things, motivated by the desire to get out early; hmmmmm....I might have just changed my mind a little bit
what is a "'Rogers'"?

i figured if it was adolescents, probably not voluntary,lol

a rogers is a legal order mandating medication....can be im i believe.....this guy is actually not ill, and using the system to house and feed himself, or is ill enough he needs longer term rx; in my humble, nonpsych nurse opinion!

Jules A, MSN · Sep 13, 2009

you are the "proper people"; congrats on the promotion; so what do you do with these folks?

I'm not sure where you are practicing but in my area our DON, facility administrator or even the Physician does not have the legal right to just kick people out based on their actions even when they are criminal. Psychiatric treatment takes a long time, many tries and often is not successful. In the meantime I carry on as indicated in my original answer. These people all have problems there will be malingerers, con artists and criminals that will have to be cared for and in my experience getting the word out in the psychiatric community isn't very effective especially not with career malingerers or the truly psychotic. But thanks for the promotion.

PMHNP10 · Sep 13, 2009

I'm not sure where you are practicing but in my area our DON, facility administrator or even the Physician does not have the legal right to just kick people out based on their actions even when they are criminal. Psychiatric treatment takes a long time, many tries and often is not successful. In the meantime I carry on as indicated in my original answer. These people all have problems there will be malingerers, con artists and criminals that will have to be cared for and in my experience getting the word out in the psychiatric community isn't very effective especially not with career malingerers or the truly psychotic. But thanks for the promotion.

someone in every facility has the "power" to determine how to manage a given situation, whether it's as part of a committee, or if you are the owner/founder of a private facility; there are rules in place and consequences for violating those rules, whether it would be a change in the treatment plan, expulsion from the program, or loss of privileges; so the scenario is that you are to pretend you are the person who must decide how to proceed; so how would you proceed/what would you recommend?

or if this still doesn't sit well with you, pretend you are making up the rules/consequences for a new program; what would you have in place for the given scenarios, should they occur in your program?

rachelgeorgina · Sep 15, 2009

1) John, is participating in an outpatient substance abuse research program. As part of the program, she receives a voucher to be turned in to the business office for money as compensation for her participation in the study. One day, Mary decides to place an additional 0 at the end of the dollar amount. The business office notices this addition and calls the clinic to verify.

If Mary/John is participating in an outpatient research program it sounds like she is relatively stable and can be kicked out of the program as a consequence for her action (which is probably lawfully wrong - fraud/stealing.) However, that said, obviously Mary/John is psychiatrically unwell to some degree and removing her from the program with no follow up or care will be almost definitely detrimental to her health. Is it her first "offense"? Is a good talking to and a path of potential consequences all that is needed to send home the message that she has done the wrong thing and it will not be tolerated? Or is she a chronic offended who is non-compliant with treatment and doesn't want to be there?

2) Billy, Jeff, Carl, and Darryl are adolescent patients in a residential substance abuse treatment program. They decide to bring assorted products back from the cafeteria (e.g., fruit, sugar, bread) and make their own alcohol. Staff, during a search find the fermenting concoction.

These three probably don't want to be in treatment to start with. They probably need a lot of education (and experiences that hit home) before recovery becomes a real potential in their minds. As they are young, probably don't want to be there and will probably go straight back to their DOC as soon as they get out, I think they should be kept in the program with some serious consequences on how they are effecting their and others recovery. Separating the three and supervising their time in the cafeteria and otherwise seems appropriate also. A strike system may be in order, also, which increasing consequences for each new offense.

3) Jill, Mary, and Joe are patients in an inpatient psychiatric facility for depression. They decide to cheek their meds and at night crush them and snort them. Staff walk in on the trio while inhaling their crushed meds.

These three probably don't want to continue to suffer from depression but are to young and to sick to understand the important of compliance with the therapeutic regime. They're probably also bored and ****** off about being stuck in a crappy hospital. I think separating the three and increasing supervision in regard in meds (mouth checks at each dose) is a good place to start, as well as a hell of a lot of education.

5) Vince has been hospitalized in your inpatient psychiatric unit 3 times in the past 2 months. His story each time he presents to the ER is that he is depressed, suicidal with a plan to walk into traffic, and hearing voices that tell him to harm himself. He also reports using crack cocaine on a regular basis. At each discharge there is a plan established, but he does not follow through on his end, only saying that he can't. When he gets onto the unit, he becomes demanding for food and medications (pain meds and psychotropics that will knock him out), refuses to take a majority of his non-sleep inducing psychiatric medications, and is disruptive to the millieu.

5) Vince sounds like he needs a good talking to and to be made aware that he actions are starting to become fairly transparent. I would suggest that Vince was encouraged or forced to attend appropriate substance abuse treatment, educated appropriately about the drugs, his illness and their effect (which I expect has been done) and arrange for a community treatment order following discharge so that he DOES follow up with his discharge planning in order to prevent a future admission for the same reason. It sounds like Vince needs steel consequences for his actions in order to reinforce their negative and unhelpful nature and encourage compliance with the therapeutic regime. Perhaps explaining to Vince that the physician prescribes drugs, not the patient, wouldn't go astray, either.

GalRN · Oct 20, 2009

A "Rogers" is an court order requiring a pt to take medication and/or comply with medical tests and possibly tx's. We recently had a woman who would have chosen to receive tx if her delusion hadn't been centered around the fact that her food and meds were tainted. She almost died from a very low K+ level by the time the judge came through. She's doing much better now- taking PO meds and showering, etc.

She is a lawyer and LicSW BTW, was just too delusional to help herself.