D.24 SOP-BH-01 One-to-One Observation for Suicide Risk.pdf

ONE-TO-ONE OBSERVATION FOR SUICIDE RISK AT BUTLER VA HEALTH CARE

SYSTEM

SOP BH-01

Butler VA Health Care System Butler, PA 16001

Signatory Authority:

Director

Responsible Owner:

Suicide Prevention Coordinator

Service Line(s):

All Services lines

Effective Date:

February 24, 2020

Recertification Date:

February 24, 2025

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures for one-to-one (1:1) observation for suicide risk at Butler VA Health Care System. This SOP must be followed by any Butler VA staff member who is specifically trained and competent to provide direct observation if a Veteran presents to the Health Care Center (HCC), Domiciliary, Community Living Center (CLC) or Community Based Outpatient Clinic (CBOC) and is determined to be at imminent risk of self-directed violence or violence towards others.

b. This SOP sets forth mandatory procedures and processes to ensure compliance with Butler VA Medical Center Policy (MCP) PC-15, VHA Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients, Acting Deputy Under Secretary for Health for Operations and Management (10N) (DUSHOM) Memorandum, “Acute Mental Health Unit and Non-Mental Health Unit One-To-One Observation for Suicide Risk,” dated May 10, 2019, the Joint Commission Behavioral Health Standards and National Patient Safety Goal for Suicide Prevention,15.01.01

c. As stated in VHA Directive 1167: 1:1 observation is defined as the constant observation of one Veteran by one staff. Staff providing 1:1 observation should only be observing one Veteran at a time and have no other responsibilities during the assignment to 1:1 observation. While under 1:1 observation, any restroom visit requires an escort who can visually monitor the Veteran for suicidal behavior. Such restrictions on the Veteran’s freedoms must be consistent with statutory and regulatory authority and be sensitive to privacy and dignity. Observation by cameras cannot substituted for 1:1 observation.

d. Butler VA is not ligature resistant. Continuous monitoring in a safer location while awaiting transfer to higher level of care will be performed. The clinical area will be assessed to identify objects that could be used for self-harm and should be routinely removed, when possible, from the area around a Veteran who has been identified as high risk for suicide. (See Attachment A)

2. PROCEDURES

February 24, 2020 SOP-BH-01

a. If a Veteran verbalizes having thoughts that he/she would be better off dead or in hurting themselves, do not leave the Veteran alone.

b. If at any time the Veteran becomes threatening toward others or him/herself, notify the VA Police or local Police at CBOC.

c. Once the Veteran is determined to be at imminent risk to self or others, 1:1 observation will be maintained with the Veteran.

d. When a Veteran is placed on 1:1 observation for suicide, actions are taken to decrease environmental risks by utilizing the Suicide Prevention Tool for Veterans Outside of a Locked Mental Health Unit as a guide in identifying environmental risks.

Items that may pose risk of harm without compromising care are to be removed from the room. Remove and/or monitor closely any items that can be used as a weapon to harm self or others. Remove and/or monitor closely all unnecessary ligature points.

(See Attachment A)

e. The Veteran is not to be left alone at any time. The Veteran is not permitted to smoke or leave the room for any reason other than use of the bathroom. The Veteran must be accompanied and observed if he/she requires use of the bathroom if the Veteran asks to use the restroom, the door is to remain open and he/she is to be directly observed. If requested by the Veteran, bathroom watch will be conducted by gender specific staff.

f. Once the Veteran is placed on a Voluntary 201 or Involuntary 302 commitment; a safety check will be completed to ensure that the Veteran does not have any weapons or contraband. The search will be conducted as soon as possible after determination that a transfer is warranted and prior to transfer of the Veteran.

g. Once the search is completed, the Veteran is not permitted access to the items removed during the search. The Veteran’s personal belongings are handed off to the transport team or family member if present.

h. The Veteran is to remain on 1:1 observation until a qualified provider discontinues the 1:1 because the Veteran is determined to not be a “suicide risk” or is transferred to a higher level of care.

i. Document in CPRS that the 1:1 continuous monitoring was maintained and by whom, and actions were taken to decrease environmental risks.

j. See Attachment B for location-based algorithms.

3. ASSIGNMENT OF RESPONSIBILITIES

a. Qualified Clinicians are responsible for evaluating Veteran as risk for suicide and determining level of severity.

b. Clinical managers and Supervisors are responsible for ensuring that safety procedures for high risk Veterans are followed and ensuring that all designated employees complete training and is included as part of the employee’s competency plan.

c. VA Police are responsible for defining safety check and carrying out the required search at the HCC, CLC and Domiciliary.

d. Butler VA employees who are trained and deemed competent are responsible for carrying out the procedures in this SOP.

4. REFERENCES

a. Butler VA Health Care System Medical Center Policy PC-15, Management of Suicidal Veterans.

b. Suicide Prevention Tool for Veterans Outside of Locked Mental Health Unit

c. 2020 National Patient Safety Goals- The Joint Commission: National Patient Safety Goal 15.01.01 updated November 20, 2019

d. VHA Directive 1167, Mental Health Environment of Care Checklist for Mental Health and Non-Mental Health Units Treating Suicidal Patients.

5. REVIEW

Review at a minimum at recertification, when there are changes to national policy or a health care accreditation body mandate, and any regulatory requirement for more frequent review. Review conducted by Behavioral Health Committee.

RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of February 24, 2025. In the event of contradiction with national policy, the national policy supersedes and controls.

6. SIGNATORY AUTHORITY

BARBARA FORSHA, MSN, RN, ET

Interim Director February 24, 2020

Peter Albert Suicide Prevention Coordinator February 24, 2020

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: Emailed to the Butler All Exchange Distribution List on March 30, 2020.

SOPs are available at:

https://dvagov.sharepoint.com/sites/VHABUTvamc/Policies/default.aspx https://dvagov.sharepoint.com/sites/VHABUTvamc/Policies/default.aspx

APPENDIX A

A-1

APPENDIX A

SUICIDE PREVENTION TOOL FOR VETERANS OUTSIDE OF LOCKED MENTAL

HEALTH UNIT

When a Veteran is placed on 1:1 observation for suicide, actions to decrease environmental risks are necessary. This tool is to assist in identifying environmental risks.

• Items that may pose risk of harm without compromising care are to be removed from room.

• Remove and/or monitor closely any items that can be used as a weapon to harms self or others.

• Remove and/or monitor closely all unnecessary ligature points.

TABLE 1: VETERAN SAFETY CHECK

➢ Veteran searched

➢ Veteran personal belongings removed, labeled and placed in an area inaccessible to the Veteran

➢ Non-essential bedside equipment removed (tubing, etc.)

➢ Unnecessary cords removed (telephone, call bell) or closely monitored

➢ Plastic trash bags/liners removed from the room

➢ Cabinets locked and secured or emptied

➢ Sharps container checked, not more than half full and no sharps protruding

➢ Monitor bathroom use.

➢ Qualified staff to accompany Veteran from one area of the facility to another

TABLE II: EXAMPLES OF POTENTIALLY DANGEROUS ITEMS

Products containing alcohol (Mouthwash, Hand rub)

Sani-wipes

Cosmetics/Perfume/Aer osols (deodorant, hair spray)

Lighters

Dental floss

Sharps (razors, safety pins, metal nail file, nail

Medical Equipment (Oxygen flow meter, suction canister, suction tubing, ambu bag, thermometer, IV pumps & tubing, telemetry cables)

Safe Veteran Handling Equipment/Trapeze bars

Plastic Items (bags/trash liners/food wrappings/medicine cups)

Curtains/rods/hooks/clips/blind cords

Cell phones/Pagers

Personal CD/DVD devices and cassette tapes

Battery operated electronics including TV remote

Electric items (cords/sockets, hair dryer, curling irons)

Utensils

A-2 clippers, pens, pencils, spiral bound notebooks, scissors, aluminum cans, metal hangers)

Glass/mirrors

Jewelry (Paracord bracelets)

Cords (Call bell, lights, phone, computer)

Belts/Neckties/Shoelaces/

Drawstrings/Pantyhose/socks

Linens

Heavy books/journals

Exam gloves

Chair/Over the bed tray table

TABLE III: EXAMPLES OF POTENTIALLY DANGEROUS ITEMS AT ROOM

ENTRANCE OR OUTSIDE OF ROOM DURING TRANSPORT TO ANOTHER AREA

OF CARE

Carts/Work Stations on Wheels

Bathroom/Closets/Utility Rooms

Medical equipment used during transport and in other area of care.

Windows

Elevators/Stairways

APPENDIX B

B-1

APPENDIX B

1:1 OBSERVATION – HCC, CLC, DOMICILIARY, CBOC

B-2

B-3

B-4