OPERATING PROCEDURE Florida State Hospital

NO. 155-30 Chattahoochee, Florida

July 26, 2010

Mental Health

TRANSPORTING AND SPECIALING SECURE FORENSIC RESIDENTS

AWAY FROM THEIR ASSIGNED UNIT

1.  Purpose: To establish policy for the adequate supervision of forensic residents when they are away from their assigned secure unit.

2.  Scope: This procedure applies to all Florida State Hospital Forensic Services, Security, and Unit 31 employees.

3. Training Requirements: Direct care staff in Forensic Services and Unit 31 will be trained on this operating procedure upon hire into the position during Discipline-Specific Education and by their supervisor when the operating procedure is revised. Forensic Unit Directors, Unit 31 Director, Forensic Recovery Team Members, Unit 31 Nursing staff, and Security personnel will be trained on this operating procedure upon hire into the position during Worksite Orientation and by their supervisor each time the operating procedure is revised.

4. References:

a. Florida State Hospital Operating Procedure 95-4, Contraband Control.

b. Florida State Hospital Operating Procedure 150-14, Medical Restraints and Safety Devices.

c. Florida State Hospital Operating Procedure 150-56, Assigned Clinical Observation.

d. Florida State Hospital Operating Procedure 151-2, Documentation on Flow Sheet.

e. Florida State Hospital Operating Procedure 155-22, Seclusion and Restraint.

f. Florida State Hospital Operating Procedure 155-26, Clinical Risk Assessment for Residents and Management of High Risk Residents.

g. Forensic Services Operating Procedure 155-1, Activity Log.

5. Definition of Terms:

a. NGI: Not Guilty by Reason of Insanity--Resident has been adjudicated as Not Guilty by Reason of Insanity and committed to the Department of Children and Families for treatment.

b. ITP: Incompetent to Proceed--Resident has been found Incompetent to Proceed through any stage of the judicial process and committed to the Department of Children and Families for treatment and further evaluation of competency.

This Operating Procedure supersedes: Operating Procedure 155-30, dated August 22, 2008

Office of Primary Responsibility: Forensic Administrator

Distribution: Florida State Hospital Computer Network Users

Operating Procedure 155-30 July 26, 2010

c. Risk III: A resident will be assigned to this security risk upon admission until he/she can be assessed by the Recovery Team. The Recovery Team will assign this security risk for persons who are considered to be a major risk of escape or dangerous behaviors based on history, threats, or other behaviors that might require this level of supervision. This risk level requires placement of a resident in cuffs attached to a belt before leaving the unit and escorted by two (2) employees at all times while outside the secure setting of Forensic Services. An exception will be made when the resident is admitted to Unit 31. The number of escorts will be determined by the resident’s current behavior. A resident will be monitored by one (1) employee if no documented incidents occurred in the last 48 hours of residence in Unit 31.

d. Risk II: A resident will be assigned to this security risk if he/she is considered to be a significant risk of escape or inappropriate behaviors, based on history, threats or other behaviors that might require this level of supervision. This risk level requires placement of a resident in cuffs attached to a belt before leaving the unit and escorted by one (1) employee at all times while outside the secure setting of Forensic Services.

e. Risk I: A resident will be assigned to this security risk under the following conditions:

(1) Not Guilty by Reason of Insanity--If after 30 days in Forensic Services, he/she is not considered to be a significant risk.

(2) Incompetent to Proceed--If after at least 180 days in Forensic Services, he/she is not considered to be a significant risk.

(3) Residents assigned a Risk I security level will be assigned an escort according to where the resident is assigned (Unit 31, Tallahassee Memorial Hospital, outside medical appointments.)

f. CVO: Close Visual Observation--An assigned staff member maintains close visual observation of a resident with no physical barriers that obstruct access to the resident. The resident is to be visually observed continually while on this observation status. Documentation consists of a notation on a Flow Sheet (Florida State Hospital Form 15) or on the Special Observation Progress Note (Florida State Hospital Form 59) at least every 15 minutes with end of shift summarization in the progress notes.

g. Security Restraints: Security restraints are required to ensure the safety of the resident and staff from any attempts of the resident to escape the care given to them while outside the secure compound of Forensic Services or Florida State Hospital Campus.

(1) 2-Point Security Restraints--The 2-point security restraint can be two wrists restrained to a waist safety belt/sand chair or bed, one wrist and one ankle secured to a bed or chair, two ankles secured to a chair or bed. Rotation and site shall be at the discretion of the escorts according to the needs and comfort of the resident requiring special care.

(2) 1-Point Security Restraint--The 1-point security restraint can be one wrist restrained to a waist safety belt/sand chair or bed, or one ankle to a bed or chair. Rotation and site shall be at the discretion of the escort(s) according to the needs and comfort of the resident requiring special care.

h. 1 to 1 Observation: An assigned staff member maintains continuous visual contact and remains within arm’s length of the resident at all times, unless clinically contraindicated with an order. Documentation consists of notation on a Flow Sheet (Florida State Hospital Form 15) or on the Special Observation Progress Note (Florida State Hospital Form 59) at least every 15 minutes with end of shift summarization in the progress note.

i. Escort(s): The home unit employee(s) accompanying the resident while outside the security perimeters of Forensic Services or while off Florida State Hospital campus.

6. Procedure for determining risk levels, attending scheduled appointments off Florida State Hospital grounds and outside the Forensic units

a. Security Risk Level Determination: Upon admission the resident will be evaluated and assigned a risk level of III, II, or I. The level will be documented in the progress notes, treatment order section of the ward chart, and a label indicating the risk level affixed to the front of the chart. The risk level will be reviewed at the monthly review, or sooner if needed, and changed if necessary. Any changes will be documented in the progress notes, the treatment order section of the ward chart, and a new label affixed to the front of the chart.

b. Freedom of Movement: While a Florida State Hospital Forensic Services resident is outside of the secure forensic unit for any type of scheduled assessment, no “Freedom of Movement” shall be allowed.

c. Behavior Changes/Appointments: If a resident’s behavior is violent in the 72 hours preceding a scheduled appointment, the Unit Treatment and Rehabilitation Senior Supervisor I/designee shall inform the team Mental Health Program Analyst and nurse on regular working days or the Unit Treatment and Rehabilitation Senior Supervisor II and pod nurse after hours/weekends/holidays. These staff shall make the determination of whether it is feasible to send the resident to the scheduled appointment. The Unit Treatment and Rehabilitation Senior Supervisor II/designee shall be responsible for notifying the front office and nurse of the need to cancel the appointment and reschedule if needed. Documentation in the progress notes shall be made by the Unit Treatment and Rehabilitation Supervisor I and nurse on the cancellation of the scheduled appointment and notification of the medical/psychiatric physician who scheduled the appointment.

d. Escorts/Security Restraints: Anytime a resident leaves the secure compound of Forensic Services or Florida State Hospital campus, the Unit Director, Unit Treatment and Rehabilitation Senior Supervisor III, or in their absence, a designee, in consultation with the ward supervisor (Unit Treatment and Rehabilitation Supervisor I), and other direct care staff, shall assign the number of employees required for the escort service. All temporary security changes shall be at the direction of the Unit Director, Unit Treatment and Rehabilitation Senior Supervisor III, or in their absence, a designee. If the escort(s) believes that the security category should be changed, they shall immediately contact the Unit Treatment and Rehabilitation Senior Supervisor III or designee, regarding the need for a re-evaluation of the resident. Removal of restraints for exams or medical purposes shall be at the discretion of the escort(s) or determination can be made after the escort(s) calls the Unit Director or designee for instructions.

(1) Risk III residents shall be escorted by two (2) staff members (with one [1] of the same gender as the resident), when outside the secure compound of Forensic Services. The resident shall be placed in 2-point security restraints (wrist cuffs attached to a waist belt before leaving the unit) and leg shackles. The staff escorts must keep one hand on the restraint belt while the resident is ambulating. The escorts must hold on to the main portion of the belt and not the tag end of the belt.

(2) Risk II residents shall be escorted by one (1) staff member when outside the secure compound of Forensic Services. The resident shall be placed in 2-point security restraints (wrist cuffs attached to a waist belt before leaving the unit). The staff escorts must keep one hand on the restraint belt while the resident is ambulating. The escorts must hold on to the main portion of the belt and not the tag end of the belt.

(3) Risk I residents shall be escorted by one (1) staff member when outside the secure compound of Forensic Services. Security restraints will not be required unless specifically ordered by the attending psychiatrist.

e. Exam/Assessment: Removal of the restraints for exams or medical purposes shall be at the discretion of the escort(s) and the attending physician or determination can be made after the escort(s) calls the Unit Director/Unit Treatment and Rehabilitation Senior Supervisor II or designee for instructions. Rotation of the restraints shall be considered before complete removal is attempted. If the physician orders that all of the restraints be removed for the exam, the escorts shall notify Security before this is performed. In an emergency, Security can be notified while the restraints are being removed.

f. Escorting Residents to X-ray/Eye Clinic in Unit 31: When large numbers of residents routinely go to X-ray and Eye Clinic requiring the use of a hospital bus, Units 23 and 24 shall coordinate with each other to accomplish this task. Units 23 and 24 shall rotate designated Unit Treatment and Rehabilitation Senior Supervisors I or designees to coordinate the movement of the residents to X-ray, Eye Clinic, and return to the Forensic facility. If a resident is Risk III, a 1 (staff) to 1 (resident) ratio shall be maintained. If a resident is Risk II or I, a 1 (staff) to 2 (residents) ratio shall be maintained.

g. Leaving Forensic Admissions and Evaluation Area: Residents shall be escorted from the units to the bus. The Security Department will escort the bus from Forensic Admissions and Evaluation to Unit 31. When arriving at Unit 31, the residents shall be escorted to the waiting area and remain there until all residents have been X-rayed or seen in the Eye Clinic. All staff assigned shall remain with the residents at all times.

h. Returning to Forensic Services Unit: Upon completion of verification that all residents are accounted for, the bus shall return residents to their respective Forensic unit to be escorted back to their ward/pod. The ward staff will contact “Security Control #5” via the radio and request assistance in observing the movement of the bussed residents as they reload the bus. The actual reloading of the bus shall not normally commence until the bus and a security patrol vehicle are stopped and ready at the scene.

i. Fresh Air Breaks While Away From Secure Environment: Fresh air breaks will not be provided when residents are being escorted for X-ray/Eye Clinic. Smoking is not permitted in state buildings, vehicles, or anywhere at Florida State Hospital.

j. Resident’s Restroom Use: If the resident is a Risk III, II, or I, they shall have an escort or escorts at all times. The escort of the same gender as the resident shall accompany the resident into a toilet area and shall maintain close visual observation while the resident is in the toilet area. The escort shall be allowed to release the hold on the restraint belt and maintain close visual observation. If needed, the 2 or 1-point security restraints may be rotated to 2-points to ankles to allow for toileting needs. The ankle restraints shall be in place before removing the 1 or 2-point to the wrists. If there are two (2) escorts, the second escort shall be stationed immediately outside the toilet area/entrance while the resident is in the bathroom area. If both escorts are of the same gender as the resident, they must both escort the resident into the toilet area and maintain constant visual observation with the resident.

7. Procedures for Residents Admitted to Unit 31:

a. Orders: When a resident is admitted to Unit 31, the Mental Health Program Analyst or designee shall communicate with the admitting physician on the risk level needed. The attending physician shall document the discussion and write the order for Risk III, II or I level of care. Unless medically contraindicated the care of the resident shall be consistent with the risk level order as outlined in this procedure. If it is medically contraindicated the requirements for the varying levels of security may be changed. This will require consultation between the Recovery Team, the attending Physician/Advanced Registered Nurse Practitioner, appropriate personnel in the medical unit, and Security Department. A note will be made in the progress notes indicating the rationale for the exception and that the meeting took place.