Name of Policy: Policy Number: 3364-120-14 PROCEDURE FOR VOLUNTARY AND INVOLUNTARY ADMISSIONS Department: Approving Officer: Responsible Agent: Scope: Senior Behavioral Health Director ofnursing/cno and Medical Director of Senior Behavioral Health Director ofnursing/cno The University of Toledo Medical Center Effective Date: 12/2015 Initial Effective Date: 6/1114 New policy proposal Major revision of existing policy -=X- Minor/technical revision of existing policy Reaffirmation of existing policy (A) Policy Statement It is the policy of Senior Behavioral Health to admit all individuals who request treatment, meet admission criteria and are found to be clinically suitable for voluntary treatment by the psychiatrist. Further, it is the policy of the unit to process each admission in a manner that creates the least possible stress for the patient, while offering maximum protection of the patient's rights. (B) Purpose of Policy To describe admission procedure for either voluntary or involuntarily admitted patients per state standard. To define the conditions under which persons shall be admitted under voluntary status. To define the procedures for admitting voluntary patients. To define the method of informing the patient regarding right to withdraw from treatment. (C) Procedure The Medical Director or designee shall evaluate an individual's suitability for voluntary admission based upon the following criteria: A. The person has a psychiatric condition, which can benefit from inpatient treatment and is consistent with the admission criteria of Senior Behavioral Health (see admission criteria policy 3364-120-06). B. All appropriate alternatives to inpatient care have been explored through consultation with the patient refetting party if authorized by the patient. C. Lesser restrictive treatment has failed or is not suitable at the time of admission, as determined by "B" above. INVOLUNTARY ADMISSION A. Per Ohio Revised Code 5122.01 (B) or 5122.141 B. See Attached Procedure
3364-120-14 Procedure for Voluntary and Involuntary Admissions Approved by:,_ -.. ( ). }tt tll <Iii ii Monecca Smith, MSN, RN Director ofnursing/cno. 'J.I!Lll - l!/ i V tl. [ )- _:;J. r.; r:jj I~ / j { {~ 0 Date ft- ~--- ~ Bryan Moloney, MD. Medical Director Review/Revision Date: 12/2015 Written by: Carol A. Schaaf, RN, MPA Program Director Review: 12/2015 Revision Completed By:Michael Lamie, Mo Smith Policies Superseded by This Policy: New Next Review Date: 12/2018
[UTMCLogo] Exhibit A APPLICATION FOR EMERGENCY ADMISSION ("PINK SLIP FORM") I am a (select one): D psychiatrist, D licensed clinical psychologist, D licensed physician, D health officer, D parole officer, police officer or sheriff and have reason to believe that And that the Person (select one of the following): ("Person") (Printed name of Person for which this application is being completed) D Represents a substantial risk of physical harm to self as manifested by evidence of threats of, or attempts at, suicide or serious self-inflicted bodily harm; D Represents a substantial risk of physical harm to others as manifested by evidence of recent homicidal or other violent behavior, evidence of recent threats that place another in reasonable fear of violent behavior and serious physical harm, or other evidence of present dangerousness; D Represents a substantial and immediate risk of serious physical impairment or injury to self as manifested by evidence that the person is unable to provide for and is not providing for the person's basic physical needs because of the person's mental illness and that appropriate provision for those needs cannot be made immediately available in the community; OR D Would benefit from treatment in a hospital for the person's mental ijjness and is in need of such treatment as manifested by evidence of behavior that creates a grave and imminent risk to substantial rights of others or the person; That the person represents a substantial risk of physical harm to self or others if allowed to remain at liberty pending examination. Printed Name and Title of Psychiatrist, Physician, Psychologist or Officer Completing this Form Signature of Psychiatrist, Physician, Psychologist or Officer Completing this Form Date: [See Policy 3364-100-45-23 for Proper Use and Completion of this Form] 8
AFFIDAVIT (Mental Illness) Exhibit B APPLICATION FOR JUDICIAL ADMISSION In Accordance with 5122.01 & 5122.11 of O.R.C. The State of Ohio, Lucas County, s.s. PROBATE COURT ---::-:-----:-----:---=:-------------------the undersigned, residing at (Your name/name of person filing) ----------------------- says that he or she has information to believe, Or has actual knowledge that----------------------------- (Person needing help (Respondent) Represents a substantial risk of physical harm to self as manifested by evidence of threats of or attempts at suicide or serious self-inflicted bodily harm; OR Represents a substantial risk of physical harm to others as manifested by evidence of recent homicidal or other violent behavior or evidence of recent threats that place another in reasonable fear of violent behavior and serious physical harm; OR Represents a substantial and immediate risk of physical impairment or injury to self as manifested by evidence that he is unable to provide for and is not providing for his basic physical needs because of his mental illness and that appropriate provision for such needs cannot be made immediately available in the community; OR Would benefit from treatment in a hospital for mental illness and is in need of such treatment as manifested by evidence of behavior that creates a grave and imminent risk to substantial rights of others or self. (Specify category(ies) above with X),,...-~~-...------------------ (Your Name) further states that the facts supporting this belief are as follows: -=--:':""~~--:-----:---:-----:-~"'!""':'-------------- (Describe what you've seen or heard respondent do) These facts being sufficient to indicate probable cause that the above-named person is a mentally ill person subject to hospitalization by Court order. The name and address of patient's last physician or licensed clinical psychologist is.--:::::---:---::-::::---:---- (Doctor, LCP name) whose hospital residence address is:-------------------------- The name and address of respondent's legal guardian or spouse is: 9
who resides at ; and that the names and addresses of the competent adult next of kin of ----------------------who are residents ofthe County are as follows: NAME AGE KINSHIP ADDRESS That the following constitutes additional information which may be necessary for the purpose of determining respondent's County of residence: Dated this d.ay of, 20. Sworn to before me and signed in my presence on the day and year above date. PROBATE JUDGE WAIVER DEPUTY CLERK I, the undersigned affiant, hereby waive the issuing and service ofnoticeofthe Hearing on the Affidavit and voluntarily enter my appearance herein. Dated, 20
3364-100-45-23 Involuntary Civil Commitment: Emergency ("Pink Slipping") and Judicial Hospitalization; Patients Lacking Decision-Making Capacity Person enters UTMC ED or inpatient unit with no ability or limited ability to make personal health care decisions Person fits the definition of a mentally ill person subject to hospitalization (Represents a substantial risk of physical harm to self or others) / If patient IS medically stable and refuses voluntary transfer: Primary Service for Patient contacts House Supervisor, who works with Social Workers as needed to complete documentation for Emergency Hospitalization (aka Pink Slip - found on Exhibit A) and calls Rescue Crisis Patient may be retained at UTMC for only 24 hours after form signed If patient is NOT medically stable hospital staff works to maintain the patient safely through UT Security/Police or other security as necessary. Staff consults with Social Workers to pursue potential Judicial Hospitalization or Order of Detention if necessary. Person DOES NOT fit the definition of a mentally ill person subject to hospitalization (does not represent a substantial risk of physical harm to self or others) / Patient has at Patient meets definition least minimal of person lacking decision-making capacity: any person who capacity and is is so mentally impaired as not mentally ill a result of a mental or and wishes to physical illness or leave --> Patient disability, or mental signs AMA retardation, or as a result of chronic substance forms. abuse, that the person is Transportation incapable of taking arranged if proper care of the necessary person's self or property or fails to provide for the person 's family or other persons for whom the person is charged by law to provide Primary Service will l work with House Supervisor, who will work with Psychiatry/Social Workers/ Outcomes Management as necessary to determine whether to advise the family that a guardianship is appropriate