S02 ATTACHMENT FIFTY FOUR 54 SUICIDE PREVENTION POLICY CENTER MEMORANDUM 116A 19 01.pdf

VA CARIBBEAN HEALTHCARE SYSTEM CENTER MEMORANDUM NO. 116A-19-01

SAN JUAN, PUERTO RICO SEPTEMBER 2019

SUICIDE PREVENTION POLICY

I. PURPOSE: To establish policies and procedures for the prevention, management, and treatment of suicidal behavior of patients at the VA Caribbean Healthcare System (VACHS).

II. POLICY: The VACHS has a responsibility to provide a safe environment by an early detection of life-threatening behavior. A Veteran who has been identified as a suicidal risk will be provided with the treatment services and resources available to VACHS in order to protect his/her life. The Suicide Prevention Program Staff will be immediately alerted of these patients when any provider becomes aware of their behavior and they will be placed on a high-risk list.

These patient’s medical records will be flagged. The VACHS will assist the patient and his/her family to identify and contact community resources that are potential sources of assistance to address his/her treatment needs.

III. DEFINITIONS:

A. Self-Directed Violence: Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself.

B. Suicidal Intent: There is past or present evidence (implicit or explicit) that an individual wished to die, means to kill him/herself, and understands the probable consequences of his/her actions or potential actions. Suicidal intent can be determined retrospectively and in the absence of suicidal behavior.

C. Preparatory Behavior: Acts or preparation towards engaging in Self-Directed

Violence, but before potential for injury has begun. This can include anything beyond a verbalization or thought, such as assembling a method (e.g. buying a gun, collecting pills) or preparing for one’s death by suicide (e.g. writing a suicide note, giving things away).

D. Physical Injury: A bodily lesion resulting from acute overexposure to energy

(this can be mechanical, thermal, electrical, chemical, or radiant) interacting with the body in amount or rate that exceeds the threshold of physiological tolerance (e.g. bodily harm due to suffocation, poisoning or overdose, laceration, gunshot wound, etc.). Refer to the Classification System for the Centers for Disease Control and Prevention definition.

E. Interrupted by Self or Other: A person takes steps but is stopped by self/another person prior to fatal injury. The interruption may occur at any point.

F. Suicide Attempt: A non-fatal self-inflicted potentially injurious behavior with any intent to die as a result of the behavior.

G. Suicide: Death caused by self-inflicted injurious behavior with any intent to die because of the behavior.

H. High - Risk for Suicide: Veterans may be determined to be at high risk for suicide for a variety of reasons and this is always a clinical judgment made after an evaluation of risk factors (e.g., history of past suicide attempts, patient with serious suicide ideation, talking or writing about death resulting in hospitalization, recent discharge from an inpatient mental health unit), and absence of protective factors. Identification of current serious ideation that requires an immediate change in treatment plan, such as hospitalization. Presence of any of the following warning signs:

1. Threatening to hurt or plan to kill oneself.

2. Looking for specific ways to kill oneself and seeking access to such means, as pills, and weapons.

3. Talking or writing about death, dying, or suicide when these actions are out of the ordinary for the person.

I. Suicide Risk Identification Tools: Standard operation procedure for the implementation of the suicide risk identification at the VACHS.

J. Primary Screen for Suicide Risk (Item9 / PHQ9): is a designated evidence-based tool to identify those cases who may be at risk for suicide. The I9 is specific question about death wishes. The response of greater than “Not at all” is a positive screen, and secondary screen will be required to be completed.

K. Secondary Screen Columbia-Suicide Severity Rating Scale (C-SSRS): is an evidence supported scale used for suicidality assessment. The standardized questionnaire has specific items about suicidal thoughts, plans and behavior.

L. Comprehensive Suicide Risk Evaluation (CSRE): is a new national clinical note for documentation. It captures clinical impressions about acute and chronic suicide risk and associated disposition.

IV. RESPONSIBILITIES:

A. The Director is responsible to assure the delivery of effective care and services to those patients who demonstrate suicidal behavior.

B. The Chief of Staff is responsible for ensuring the reporting and the implementation process of the Management of Suicidal Behavior Protocol.

C. The Associate Director and the Associate Director Patient Care Services are responsible for ensuring the participation of all involved staff under his/her responsibility in supporting efforts for compliance with the requirements established by this policy.

D. The Associate Chief of Staff from Behavioral Health Sciences is responsible for providing written guidelines and the oversight of implementation at Behavioral Health Services.

E. The Clinical Service Chiefs are responsible for assuring that all suicidal adverse events are properly documented and reported on e-incident report (electronic incident report) (see Attachment A), on a timely manner.

F. The Patient Safety Manager, or designee, is responsible for establishing a control system to assure that all suicidal adverse events are received for applicable Root Cause Analysis review. He/she will coordinate and oversee all activities related to suicidal adverse events including, but not limited to: data collection, review, follow-up on recommendations, tracking of corrective actions, and reporting aggregate and individual specific data, (See Attachment A).

G. The Suicide Prevention Coordinator (SPC) is responsible for training about the prevention, management and treatment of suicidal behavior to all employees during the New Employee Orientation. The staff will be provided with education and training on: Suicide/High Risk Behavior Levels (See Attachment B) and Management of Suicide High Risk Behavior (See Attachment C, D and E), and current practice update on treatment interventions. Will provide the oversight to ensure that all clinicians comply with the annual Suicide Prevention Training for Clinicians through Talent Management System (TMS). The SPC also will provide monitoring of the implementation of Suicide Prevention screenings and present the results to the Patient Safety Committee on a Quarterly Bases.

H. All providers with direct patient care duties are responsible to carry out the procedures established in this memorandum.

V. PROCEDURE:

A. The management of suicidal risk behavior varies depending on the clinical setting the patient is in. If patient is in in Primary Care (see Attachment D), Patient in Ambulatory Care Flowchart. For phone call of suicidal patients (See Attachment E) Management of phone call of suicidal patients Flowchart.

B. The Clinical Staff are responsible to carry out the procedures established in this memorandum, and to use the established tools to identify cases at risk for suicide; (See attachment F). Primary Screening is the (I(/PHQ9) If is positive, C-SSRS should be completed and if C-SSRS t is positive, the Licensed Independent Practitioner (LIP) should complete the note of Comprehensive Suicide Risk Evaluation.

C. As soon as a clinical staff member identifies a patient with high risk behavior, including but not limited to, those who have suicidal ideas and meet other criteria for high risk for suicide as well as those who have survived suicide attempts, they will be placed on the “High Risk for Suicide List” by the Suicide Prevention Coordinator (SPC) or designee. All the patients on that list will be flagged for at least 90 days. The Mental Health Licensed Independent Practitioner will document suicidal behavior in the CPRS Problem List.

D. The Suicide Prevention Team will identify patients admitted with suicide attempts via the Suicide Behavior and Overdose Report (SBOR), which is prepared by the clinician evaluating the patient. An alert (in CPRS) is automatically sent to the SPC and/or designee, including the Suicide Prevention interdisciplinary Team who are responsible for reviewing the SBOR.

E. When the patient is admitted at VA or at a Non-VA psychiatric facility after clinical evaluation is found to meet criteria for High Risk for Suicide, the patient is identified by the interdisciplinary team and the Suicide Prevention Team is notified during case discussions.

The Suicide Prevention Team will place the Flag for High Risk for Suicide Behavior based on the recommendations of the interdisciplinary team. All cases identified as a high risk for suicide will be included on the Suicide Prevention Application Network (SPAN).

F. The SPC will send a monthly list of cases who require to be re-evaluated after

90 days to the Behavioral Health Managers, for the Flag status review (continue or inactivate the flag).

G. The SPC will coordinate and report all community outreach activities in the

SPAN.

H. If the identified patient is being treated as an outpatient in the San Juan main facility, he/she will be referred to the Psychiatric Intervention Center (PIC), where the Psychiatrist on duty will perform a complete suicide risk assessment, including the Suicide Risk Evaluation Tools (See Attachment F). If the patient is at an acute high risk for suicide, he/she will be hospitalized under the appropriate safety precautions.

I. If the identified patient is being evaluated or treated by a PCMHI LIP in another

VA clinic such as a CBOC, the patient will be placed under constant observation in a secure environment. In those clinics where there is an available behavioral health clinic (BHC), patient will be placed on constant observation by the PCMHI LIP through a text order and will notify the BHC Manager or designee for proper transfer to BHC secure environment. While the patient is under constant observation in the BHC, the PCMHI will work collaboratively with the BHC Manager or designee to complete the arrangements for another level of care such as psychiatric hospitalization and complete pertinent documentation. In the absence of a behavioral health clinic in CBOC, a Mental Health Licensed Independent Practitioner (LIP) if available or the Primary Care Provider (PCP) will be responsible to place patient on constant observation and to perform the evaluation and referral for the appropriate level of care.

J. Each patient that is at a low suicidal risk based on the comprehensive suicide risk, evaluation will be discharged home with an appropriate follow up plan. This includes referral to the Psychosocial Recovery and Rehabilitation Center (PRRC), Day Hospital Program, Intensive Outpatient Program, mental health outpatient clinic and/or Primary Care Mental Health Integration program. The follow-up appointment must be provided to the patient no later than fourteen days after the initial assessment. The different treatment options should be discussed with the patient and/or family members.

K. When a patient is found at no suicidal risk in the initial clinical evaluation and comprehensive suicide risk evaluation, he/she can continue ambulatory care with the appropriate follow up coordination with his/her primary care physician or mental health provider.

L. If the patient is identified a high risk for suicide and is medically unstable while in PIC, he/she will be transferred to Emergency Department (ED) for evaluation or stabilization under constant observation, guaranteeing a safe environment for this patient. If the patient needs to be admitted to an Inpatient Medicine ward the nurse in charge of the patient care will use the Rules to be follow for the care management of Suicide Risk Patients and Inpatient Medical-Surgical Acute Care Hazardous Items Environmental Checklist for Suicide Risk Patients (Attachment G) as guidance for the patient safely care.

M. When a patient arrives to the ED with suicidal behavior and is medically stable he/she will be transferred to PIC for evaluation and disposition, also under constant observation. However, if the identified patient in the ED is medically unstable, he/she will be admitted to Medical or Surgical Service and consulted to the Psychiatry Consultation and Liaison Psychiatrist for evaluation and appropriate recommendations. If the physical condition of the patient does not permit transfer to the Acute Behavioral Health Inpatient Care Unit (ABHICU), then the patient will continue under constant observation with follow up by the Consultation and Liaison team. Upon stabilization of patient's medical or surgical condition, he/she should be transferred to psychiatric hospitalization, if clinically pertinent.

N. Patients hospitalized in Acute Behavioral Health Inpatient Care unit (ABHICU) under constant observation due to suicidal ideas or attempts will have daily reevaluation with appropriate documentation in CPRS. Patient will be followed up by the interdisciplinary team during his/her hospitalization. If a hospitalized patient threatens to commit suicide, the relatives of the patient will be directly notified by a member of the interdisciplinary treatment team in charge of the patient. The treatment team will contact the family or significant other and ask them to assist in providing support, if appropriate. When the patient's support system is poor or inadequate the treatment team will assist the patient in identifying and contacting established mental health resources in the community, e.g. Residential Programs, Crisis Centers and Support Groups. As a general rule all patients being discharged from ABHICU will have four contacts within 30 days after discharge, please refer to the Behavioral Health Memorandum No.116-14-01, Care Management Coverage for the 24-48 hours post discharge and for high risk suicide patients.

O. When a patient is identified as a high risk for suicide by the interdisciplinary team, the first option to continue care will be an Intensive Outpatient Program (IOP), and Community Care Day Hospital treatment. Consult for Community Care Day Hospital must be placed as early as possible upon identification that the referral is needed. The consult should include the expected date of discharge. If there is change in discharge date, ABHICU provider must contact Community Care staff to notify change in order to make changes in appointment coordination as needed. Community Care Day Hospital Consult must receive approval by Service Chief or designee within 24 hours. Community Care staff will coordinate the Day Hospital appointment prior to expected date of discharge and appointment will be scheduled not later than 72 hours post discharge. At time of discharge Community Care Day Hospital appointment will be informed to the patient and caregiver and documented in patient’s instructions form in computerized medical record. For patients who reside outside of the San Juan catchment area, the discharge plan may include the community IOP, or Community Care Day Hospital followed by appointments at Community Based Outpatient Clinics (CBOC's). For any patients identified as a high risk for suicide that declined treatment in IOP or Day Hospital, will have weekly follow up by the qualified mental health clinical staff for the first month, then monthly until completion of the 90 days post discharge.

P. All Veterans hospitalized at the ABHICU will have completed the Safety Plan before discharge.

Q. For patients evaluated in a Community Based Outpatient Clinic (CBOC) the following procedure applies:

1. Once the patient is identified with active suicidal ideas, agitated and/or with homicidal ideas the clinic nurse or staff member must place the patient under constant observation. The patient will be evaluated by a Mental Health Licensed Independent Practitioner (LIP) and other members of the clinical team such as Social Worker will be immediately notified.

2. The patient must be evaluated by the Mental Health LIP within the next hour. The LIP starts the process of referral and admission in communication with the San Juan Facility Psychiatric Intervention Center and/or private Hospital Facility. The Inter Facility Transfer policy (Center Memorandum No. 136-14-14) must be followed. In the case that the LIP is not a physician, he/she will request the assistance of another physician (not psychiatrist) in completing the needed documentation for transfer and hospitalization.

3. In case that the patient refuses the hospitalization process, the patient must be held until a relative is reached and oriented about the current patient’s risk and the state laws on involuntary admission. All interdisciplinary approaches should be extinguished in order to talk down the patient into acceptance of the admission. In the absence of a family member, the VACHS staff will be responsible for obtaining the involuntary hospitalization court order as described in the Involuntary Mental Health Services Center Memorandum 116A-13-

02. This applies for patients evaluated anywhere in the VACHS, main facility and CBOC.

4. The Mental Health LIP must complete all needed documentation as per the Management of the Psychiatric Patients Requiring Inpatient Hospitalization SOP.

5. Staff who completed the clinical evaluation will make all efforts to find an available inpatient bed in the nearest location to the patient’s area of residence, if no available bed in a Non- VA facility is found or the patient is not a candidate for a Non- VA facility, arrangements will be made to transfer the patient to the SJVAMC. In all instances, the inter-facility transfer process must take place as described in the Standard Operating Procedure for the Management of Psychiatric Patients Requiring Inpatient Hospitalization.

R. After discharge from psychiatric inpatient hospitalization, the frequency of follow-up appointment will be determined according to the individualized treatment plan as established by the treatment team.

S. All Veterans will be screened annually using the Depression and PTSD screening tool.

T. For patients evaluated in the Home Care Program setting:

1. The Primary Care Provider (MD or Nurse Practitioner) will do the initial Depression screening (PHQ 2 or PHQ 9, Geriatric Depression Scale or Cornell Depression

Scale). In case the screening cannot be completed within the required timeframe, the Social Worker will assist with this task.

2. If the initial screening is suggestive of depression, the provider will refer the patient to the Mental Health provider for treatment and close follow up. Positive screening require inquiry about access to firearms or lethal weapons, and education regarding home safety precautions for the patient and visiting staff.

3. If the patient is identified with active suicidal ideation, homicidal ideas, and/or abrupt behavioral or disruptive personality changes during a home visit, a Comprehensive Suicide Risk Assessment should be performed, and the staff member must:

a. Identify the psychiatric emergency and call 911.

b. Ask the caregiver/family/home staff for assistance to provide constant patient observation to ensure his/her safety.

c. Reassess potential environmental hazards that can be used as lethal weapons while waiting for 911 assistance.

d. Refer case to a Mental Health Provider at the designated CBOC, the HBPC psychiatrist or PIC.

4. The LIP initiates the referral process for psychiatric admission by communicating with the San Juan Facility Psychiatric Intervention Center (PIC) and/or psychiatric community hospital closest to the patient’s home. The inter-facility transfer policy (Center Memorandum No.136-14-14) must be followed. In the case that the LIP is not a physician, he/she will request the assistance of another home care physician for completion of the required documentation.

U. The following procedure applies based on the high risk for suicide status at the time of discharge:

1. If the patient does not show for their appointment, the provider should contact the patient by phone (Guidance on the Management of Failure to attend Mental Health Appointment Memorandum 116-12-01).

2. All patients identified as a High Risk for Suicide Behavior will have an individualized Suicide Prevention Safety Plan (see Attachment H). The Suicide Prevention Safety Plan is a prioritized written list of coping strategies and sources of support that the patient can use during or preceding a suicide crisis. This Suicide Prevention Safety Plan will be included in the patient’s medical record, also include directions for the veteran about how to get help 24/7, including the local VA number available (787) 787-622-4822 or 1-866-712- 4822, and the veteran crisis line number (1-800-273-TALK [8255], press 1 for Veterans).

VI. REFERENCES:

A. Brenner, Lisa, (2013) Self Directed Violence Classification System.

B. Employee Education System. (2007). Suicide Risk Assessment Guide

Reference Manual. Washington, D.C.: United States Department of Veterans Affairs.

C. Riba, M., Ravindranath, D. Clinical Manual of Emergency Psychiatry, Second

Edition 2016.

D. Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC).

E. Mills, P.D., Watts, B.V., Miller, S., Kemp, J. The Joint Commission Journal on

Quality and Patient Safety. February 2010 Volume 36 Number.

F. Schultz, J. Dark Videbeck, S. Lippincott. Manual of Psychiatric Nursing Care

Plans. Nine Edition (2012).

G. Stanley, B. & Brown, G. K. (2012). Safety Planning: A Brief Intervention to

Mitigate Suicide Risk. Submitted for publication.

H. VA/DoD Clinical Practice Guideline for Assessment and Management of

Patients at risk for suicide. Version 1.0, June 2013.

I. VHA Handbook 1051.1, Patient Safety Improvement, dated

January 30, 2002.

VII. RESCISSION: Center Memorandum No. 116A-18-01, Management of Suicidal Behavior dated December 2018.

VIII. EXPIRATION DATE: September 2022

IX. FOLLOW-UP AND RESPONSIBILITIES: ACOS Behavioral Health Sciences

//S//

CARLOS R. ESCOBAR, BED-ARCH, MSHP, FACHE

Director

VA CARIBBEAN HEALTHCARE SYSTEM ATTACHMENT A

SAN JUAN, PUERTO RICO CENTER MEMORANDUM NO. 116A-19-01

SEPTEMBER 2019

E-INCIDENT REPORT (ELECTRONIC INCIDENT REPORT) THROUGH

JOINT PATIENT SAFETY REPORTING(JPSR)

VA CARIBBEAN HEALTHCARE SYSTEM ATTACHMENT A

VA CARIBBEAN HEALTHCARE SYSTEM ATTACHMENT B

SUICIDE/HIGH RISK BEHAVIOR OBSERVATION LEVELS

Acute Behavioral Health Inpatient Care Unit and Psychiatric Intervention Center

There will be three (3) categories of suicidal behavior risk management or suicide/homicidal observation status. Each category shall have appropriate care criteria. High-risk status would be place on constant observation; moderate risk. Close I; and low risk, Close II.

1. Constant observation (one to one): direct observation with restrictions to a bedroom, removal of neckties and shoelaces and other unsafe pieces clothing. Toilet doors shall be left ajar when in use, so patients will be observed at all times by staff member. Document every 15 minutes.

2. Close I: Patient is confined to the ward. This patient will not be able to get off the ward for therapeutic activities.

3. Close II: Patient is confined to the ward. This patient will be able to get off the ward for therapeutic activities.

FOR MEDICINE OR SURGERY SERVICE

1. Constant observation (one to one): direct observation with restrictions to a bedroom, removal of neckties and shoelaces and other unsafe pieces clothing. Toilet doors shall be left ajar when in use, so patients will be observed at all times by staff member. Document every 15 minutes.

VA CARIBBEAN HEALTHCARE SYSTEM ATTACHMENT C

MANAGEMENT FOR SUICIDE RISK BEHAVIOR FLOWCHART

Clinical Pathway for patients brought to the VAMC after a suicidal attempt or considered a suicidal risk behavior

NO YES NO YES

Attempt Risk

Emergency Room

* Provide appropriate medical treatment

* Activate Protocol for Management of Suicidal Risk behavior

PIC

*Activate Suicide Protocol

Suicidal

Medically

Stable

Medically

Stable

Admit to ABHICU

Admit to *Medicine/Surgical ward

*Consult to Psychiatry *Transfer to ABHICU when medically stable

ABHICU

*Patient will be evaluated by interdisciplinary team.

* Treatment and discharge plan will be initiated upon admission.

* Patient’s family or significant other will participate in the treatment and discharge planning process as appropriate.

*Treatment plan review at least every other day or as frequently as needed.

*Make appropriate referrals.

*Early post discharge follows up will be completed.

Outpatient Follow Up

*Partial Hospitalization (Day Hospital), or Intensive

Outpatient Program.

*BH F/U (Mandatory appointment within a month-4)

*Private Psychiatrist

*Other community resources or support program

VA CARIBBEAN HEALTHCARE SYSTEM ATTACHMENT D

MANAGEMENT OF SUICIDAL PATIENT IN AMBULATORY CARE FLOWCHART

Veteran evaluated at the Outpatient clinic

Identified as a High Risk for Suicide

No Continues with ambulatory care Si

Patient is alone YesNo

Constant observation (1:1)

Main facility in San Juan

YesNo Accept go to PIC

Yes

No

Escort to PIC

Call the VA Police

Patient inside of PIC

(handoff with

RN)

Evaluation by Mental Health LIP or

Primary Care Provider for final disposition

VA CARIBBEAN HEALTHCARE SYSTEM ATTACHMENT E

MANAGEMENT OF PHONE CALL OF SUICIDAL PATIENT FLOWCHART

Receive the call

Is an

Emergency NO YES

Patient is alone NO YES

Use the other person as resource to manage the call

Call 911, still in the phone until help arrives

Orient to continue with ambulatory care

Send the patient to the community ER or

VA ER PIC

End the call

VA CARIBBEAN HEALTHCARE SYSTEM ATTACHMENT F

PRIMARY SCREENING FOR SUICIDE RISK

SECONDARY SCREEN: COLUMBIA-SUICIDE SEVERITY RISK SCALE (C-SSRS)

COMPREHENSIVE SUICIDE RISK EVALUATION (CSRE)

VA CARIBBEAN HEALTHCARE SYSTEM ATTACHMENT G

SUICIDE PREVENTION SAFETY PLAN

A Safety plan is a prioritized written list of coping strategies and sources of support that patient can use during or preceding crisis suicidal crisis. The intent of safety planning is to provide a pre-determined list of potential coping strategies as well as a list of individuals or agencies that veteran can contact in order to the lower the imminent risk of suicidal behavior.

VA CARIBBEAN HEALTHCARE SYSTEM ATTACHMENT G

VA CARIBBEAN HEALTHCARE SYSTEM ATTACHMENT H

INPATIENT MEDICAL-SURGICAL ACUTE CARE HAZARDOUS ITEMS

ENVIRONMENTAL CHECKLIST FOR SUICIDE RISK PATIENTS

Date: ___________ Time Completed: __________ Unit: _____________ Room:

Directions: A Veteran that is at risk for self-harm or harm to others has been assigned to this room/bed area. You must be acutely aware of the environment that the Veteran is in, and potential hazardous items that could cause harm. Please complete the environment checklist when setting up the room/bed area for the patient to be admitted by removing and securing the outlined items and signing the form. Upon completion, please provide one copy to the sitter and the original to the charge nurse. **All small room/bed area items are to be placed in a bath bin, stored with room number, and replaced back into room/bed area when the patient is discharged.*

Name of Equipment 12-8am Item

Removed

7:30-4p Item

Removed

3:30-12mn Item

Removed

Rationale: Why left in room

Yes No Yes No Yes No

Footboard from bed

Confirm call bell is functional (use bell on bed if possible)

Sharps container is no more than ¾ full

Computer on wheels is outside of room

IV pole

IV machine

Bedside phone and cord (obtain phone when needed by patient only)

Suction/canister adapter

Extra boxes of gloves

Sanitation wipes

Extra furniture

Bed light cord

Bathroom is free of hazardous items (wipes, etc.)

Extra medical supplies (oxygen tubing, BP cuff, etc.)

Inspect night table for hazardous items and remove

Patient care kit

Office supplies (pen, pencil, paper clips, notebooks, etc.)

Printed Name: ________________________ Signature: ____________________________

VA CARIBBEAN HEALTHCARE SYSTEM ATTACHMENT I

RULES TO BE FOLLOW FOR THE CARE MANAGEMENT OF

SUICIDE RISK PATIENTS

You have been assigned to sit with a Veteran that is at risk for self-harm or harm to others.

You must be acutely aware of the environment that the Veteran is in, and potentially hazardous items that could cause harm. Please follow the special observation guidelines/responsibilities outlined below. At the end of the shift, please return signed copy to the charge nurse.

Obtain report on the patient

Obtain the primary nurse and charge nurse’s names.

Immediately call for assistance and intervene for any safety concerns

Provide care only for the assigned patient

Eyes on the patient at all times

Stay within 4-8 feet from the patient

No employee personal belongings (including books, food, backpacks, beverages, etc.) are to be brought into the patient’s room.

No cellphone, books, newspaper, headphones, personal conversations, or other distracting items used by Caregiver

Personal calls or texting are not permitted when assigned to provide direct observation of a Veteran. (can be made during formal breaks)

Watching TV or working on the computer when assigned to monitor the patient is not permissible

Sleeping while performing monitoring is not permitted

Visually monitor the patient when in the bathroom/shower room

Do not leave the room/bed area when patient visitors enter the room/bed area

Re-observe the environment after the patient receives a personal visit

No outside items are to be given to patient by visitors without being checked by the nurse first.

Verify the environmental for the room/bed area is as stated on the environmental checklist at change of shift.

Do not leave the room/bed area when providers (physician, PT, dietitian, etc.) enter the room, except when asked by the provider o If asked to leave the room/bed area, please remain outside of the patient’s door until requested to go back into the room/bed area.

Verify the counts of the plastic/paper ware that is used for meal to ensure the number of utensils that go into the room/bed area, come out of the room/bed area.

o If metal silverware comes on food tray, remove and call for plastic ware.

Complete the sign-in and sign-out on restraints/special observation form when leaving and returning from breaks and meals, and at the beginning/end of shift

Printed Name: _________________________________________ Signature: ____________________________________________