Chapter 5122-3 Electroconvulsive Therapy; Incident Reporting; Patient Abuse/Neglect; Etc

5122-3-01 Consultation with constituencies affected by rules.

(A) Purpose.

The purpose of this rule is to establish procedures by which the department of mental health will notify and consult with relevant constituencies that may be affected by rules, standards, and guidelines issued by the department.

(B) Application.

This rule shall apply to all rules, standards, and guidelines issued by the department.

(C) Definitions.

(1) "Board" has the same meaning as community mental health board (CMH) or board of alcohol, drug addiction and mental health services (ADAMH) as defined in Chapter 340. of the Revised Code.

(2) "Consultation" means the process described in this rule for communications between the department and relevant constituencies prior to the establishment of rules, standards, and guidelines. Such communications may be written or oral, in group or individual meetings, by review of proposals or responses, or other appropriate methods.

(3) "Department " means the Ohio department of mental health.

(4) "Guideline" means a written set of principles by which to make a judgment or determine a course of action and which is required to be issued by the department under Chapter 340. or 5119. of the Revised Code.

(5) "Rule" as defined by division (C) of section 119.01 of the Revised Code, means a written statement having a general and uniform operation, adopted under Chapter 119. of the Revised Code, and enforced by the department under the authority of the laws governing the department.

(6) "Standard" means those standards required to be adopted as rules under Chapter 5119. of the Revised Code pursuant to division (G) of section 5119.01 , section 5119.20 , division (G) of section 5119.22 , and division (E) of section 5119.611 of the Revised Code.

(D) Consultation.

Prior to amending, adopting or rescinding any rule, standard or guideline, the department shall notify and consult with the relevant constituencies that may be affected by rules, standards, and guidelines issued by the department of mental health. These constituencies shall include consumers of mental health services and their families, and may include public and private providers, boards, employee organizations, and others when appropriate.

Whenever the department proposes the adoption, amendment, or rescission of rules under Chapter 119. of the Revised Code, the notification and consultation shall occur prior to the commencement of proceedings under Chapter 119 of the Revised Code.

(E) Methods of consultation with relevant constituents prior to issuing guidelines not subject to proceedings under Chapter 119. of the Revised Code may include, but not be limited to, one or more of the following:

(1) Seek input from one or more relevent constituents that have previously expressed an interest in a certain rule or standard.

(2) Convene a committee, inviting participation of representatives of relevant constituents.

(3) Any other method as may be determined appropriate based upon the subject matter of the rule.

(F) Methods of consultation with relevant constituents when proposing the adoption, amendment, or rescission of rules under Chapter 119. of the Revised Code may include, but not be limited to, one or more of the following:

(1) The department will maintain a section on the Ohio department of mental health internet website to post draft rules in order to consult with constituents prior to commencing proceedings under Chapter 119. of the Revised Code. The department will notify by e-mail relevant constituents of the posting of a draft rule, and the opportunity to provide comments for a defined period of time. In an emergency, the department may proceed directly to filing a rule under Chapter 119. of the Revised Code. An emergency includes, but is not limited to, when a delay in the issuance of a rule or standards may likely prevent complinace with federal and state laws or regulations, impede utilization of appropriated funds, pose a serious risk to the provision of mental health services or the rights of consumers, or would unnecessarily delay a regulatory reduction effort of the department.

(2) Seek input from one or more relevent constituents that have previously expressed an interest in a certain rule or standard.

(3) Convene a committee, inviting participation of representatives of relevant constituents.

(4) Any other method as may be determined appropriate based upon the subject matter of the rule.

Replaces: 5122-3-01

Effective: 02/17/2012
R.C. 119.032 review dates: 02/17/2017
Promulgated Under: 119.03
Statutory Authority: 5119.06
Rule Amplifies: 5119.06
Prior Effective Dates: 5/24/1990

5122-3-03 Evaluation and referral for electroconvulsive therapy (ECT).

(A) The purpose of this rule shall be to establish standards and criteria, indications, contraindications and limits for referral of adult ODMH regional psychiatric hospital (RPH) inpatients to an outside facility for ECT.

(B) The provisions of this rule shall be applicable to all RPHs under the managing responsibility of the department.

(C) Definitions

(1) "Chief clinical officer" and "CCO" mean the medical director of an RPH as defined in division (K) of section 5122.01 of the Revised Code.

(2) "Psychiatrist" means a licensed physician who has satisfactorily completed a residency training program in psychiatry, as approved by the residency review committee of the American medical association, the committee on post-graduate education of the American osteopathic association, or the American osteopathic board of neurology and psychiatry, or who on July 1, 1989, has been recognized as a psychiatrist by the Ohio state medical association or the Ohio osteopathic association on the basis of formal training and five or more years of medical practice limited to psychiatry.

(3) "ECT" is a somatic psychiatric treatment mediated by a modified grand mal seizure, which is induced by the application of electrical current of the brain.

(4) "Informed consent" means the voluntary and knowing permission given by a person who has received all appropriate information.

(D) Requirements for referral

(1) ECT shall not be administered in ODMH RPHs.

(2) Only adult ODMH RPH inpatients shall be referred for ECT.

(3) The RPH psychiatrist must present clinical data to the RPH CCO to obtain approval for ECT referrals.

(4) It is required that any patient, voluntary or involuntary, competent or incompetent, shall be given a full explanation of ECT consistent with the specific items cited below:

(a) An explanation of the procedures to be followed and their purposes including identification of any procedures which are experimental. This explanation is to be given in such a way as to enable the individual to make a decision to grant/deny consent;

(b) A description of any attendant discomforts and risks reasonably to be expected;

(c) A description of any benefits reasonably to be expected;

(d) A disclosure of any appropriate alternative procedures/treatments that might be advantageous for that patient including an explanation of the consequences of those procedures/treatments;

(e) An offer to answer any inquiries concerning the procedures and answers to any such inquiries;

(f) An instruction that the individual may refuse to consent and that the individual is free to withdraw his consent and to discontinue the treatment at any time without prejudice unless informed consent for the ECT is given by guardian or court-ordered; and

(g) A notification that the individual may consult with an independent specialist and counsel.

(5) The competence of a patient to give informed consent shall be determined by the attending psychiatrist. The written opinion shall be incorporated into the patient's permanent medical record.

(6) The criteria for determining the competence of the patient, include but are not limited to:

(a) Whether or not the patient is physically and mentally able to receive the information required to be furnished;

(b) Whether or not the patient is able to explain his/her understanding of the information provided; and

(c) Whether or not the patient demonstrates that he/she has evaluated the information provided.

(7) Competent adult patients

No competent adult patient shall be given ECT unless his/her informed consent has been obtained.

(8) Adult incompetent involuntary patients

(a) If an adult patient has been adjudicated incompetent to give informed consent for medical treatment by a probate court, the patient's guardian may give informed consent.

(b) If an adult patient has been determined to be incompetent to give consent according to the procedure outlined above, and has no guardian, ECT may be administered only under the following conditions:

(i) The attending psychiatrist must certify in writing that an indication for ECT use as outlined in paragraph (E) of this rule is evident;

(ii) The chief clinical officer recommends in writing the administration of ECT; and

(iii) If a durable power of attorney for healthcare issues exist, it should be followed. Otherwise, approval for ECT shall be obtained from the probate court.

(E) Indications for use

(1) General statement

Referrals for ECT are based upon a combination of factors, including the patient's diagnosis, nature and severity of symptomatology, treatment history, consideration of anticipated risks and benefits of viable treatment options, and patient preference. At present there are no diagnoses which should automatically lead to treatment with ECT. In most cases, ECT is used following treatment failure on psychotropic agents, although specific criteria do exist for use of ECT as a first-line treatment.

(2) Primary use of ECT Situations where ECT may be used prior to a trial of psychotropic agents include, but are not limited to, the following:

(a) Where a need for rapid, definitive response exists on either medical or psychiatric grounds; or

(b) When the risks of other treatment outweigh the risks of ECT; or

(c) When history of poor drug response and/or good ECT response exists for previous episodes of the illness; or

(d) Patient preference.

(3) Secondary use of ECT

In other situations, a trial of an alternative therapy should be considered prior to referral for ECT. Subsequent referral for ECT should be based on at least one of the following:

(a) Treatment failure, taking into account issues such as choice of agent, dosage, and duration of trial;

(b) Adverse effects which are unavoidable and which are deemed less likely and/or less severe with ECT; and

(c) Deterioration of the patient's condition such that criterion in paragraph (E)(2)(a) of this rule is met.

(4) Major diagnostic indications Diagnoses for which either compelling data are present for efficacy of ECT or a strong consensus exists in the field supporting such use.

(a) Major depressive disorder. ECT is an effective treatment for all subtypes of major depressive disorder;

(b) Bipolar disorder. ECT is an effective treatment for all sub-types and phases of bipolar disorder including manic, depressed and mixed phases.

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(c) Schizophrenia, schizoaffective disorder and other psychoses.

ECT may be an effective treatment for psychotic schizophrenic exacerbations including catatonia, when prominent affective symptoms are present and when there is a history of favorable response. ECT may be effective in other psychotic disorders.

(d) Mental disorders due to a general medical condition. ECT may be effective in the management of severe affective and psychotic symptoms concomitant with general medical conditions, or in treating delirium of various etiologies, including toxic and metabolic.

(e) Other diagnostic indications.

(i) For people with diagnoses for which efficacy data for ECT are only suggestive, or where only a partial consensus exists in the field, support its use. In such cases, ECT should be recommended only after standard alternatives have been considered as a primary intervention. The existence of such indications, however, should not deter the use of ECT for treatment of a concurrent major diagnostic medication.

(ii) Although ECT has sometimes been of assistance in the management of mental disorders other than those described above, such usage i snot adequately substantiated and should be carefully justified in the clinical record on a case-by-case basis.

(f) Medical disorders

(i) The neurobiologic effects associated with induced generalized seizure activity may be of benefit in treating a small number of medical disorders.

(ii) Such conditions include, but are not limited to:

(a)Catatonia secondary to medical conditions (ECT is indicated for catatonia of all causes);

(b)Hypopituitarism;

(c)Intractable seizure disorder;

(d)Neuroleptic malignant syndrome; and

(e)Parkinson's disease.

(F) Contraindications and situations of high risk

(1) There are no absolute contraindications to ECT.

(2) Situations associated with substantial risk

(a) Situations exist in which ECT is associated with an appreciable likelihood of serious morbidity or mortality. In such cases, the decision for ECT should be based upon the premise that the patient's condition is too grave, (i.e., life threatening) to leave untreated, and that ECT is the safest treatment available.

(b) In these instances, careful medical evaluation of risk factors should be carried out prior to ECT, with specific attention to treatment modifications which may diminish the level of risk.

(c) Specific conditions associated with substantially increased risk include the following:

(i) Space-occupying cerebral lesion, or other conditions with increased intracranial pressure;

(ii) Seizure disorder;

(iii) Recent myocardial infarction with unstable cardiac function;

(iv) Recent intracerebral hemorrhage;

(v) Bleeding, or otherwise unstable, vascular aneurysm or malformation;

(vi) Retinal detachment;

(vii) Pheochromocytoma; and

(viii) Significant anesthetic risk.

(d) Concomitant medications. The following medications should be discontinued or dosage reduced:

(i) Benzodiazapines, as they are anti-convulsants - should be held for at least eight hours;

(ii) Lithium, as it can increase postictal delirium and prolong seizure activity - should be reduced in dose;

(iii) Bupropion, as it can induce late appearing seizures - should be discontinued;

(iv) Lidocaine markedly increases seizure threshold - should be held for at least eight hours;

(v) Theophylline increases the duration of seizures - should be discontinued;

(vi) Reserpine can cause respiratory and cardiovascular problems and should be discontinued; and

(vii) Other medications as determined by the IBHS pharmacy and therapeutics committee.

(G) Medical evaluation When a patient remains an ODMH RPH patient when receiving ECT, the following medical evaluation will need to be completed by the ODMH RPHstaff:

(1) Medical examination;

(2) Neurological examination;

(3) Laboratory evaluations including CBC and differential; blood and urine chemistries;

(4) Electrocardiogram;

(5) X-ray of lumbosacral region if spinal problems are suspected;

(6) Chest x-ray, if clinically indicated;

(7) In the presence of central nervous system symptoms (seizure disorder or a space occupying lesion), EEG and brain computed tomographic scan or magnetic resonance imaging;

(8) Dental examination for elderly patients and those with dental problems; and

(9) Anesthesiologist consults to evaluate risk of anesthesia. This may be completed at the facility where ECT is administered prior to ECT occurring.

(H) Referred facility requirement

(1) Properly accredited hospital or outpatient facility.

(2) The psychiatrist who is responsible for the administration of ECT has been credentialed and privileged in ECT by the facility where the ECT is being administered.

(I) Training When ODMH RPH patients are receiving ECT as outpatients, the RPHnursing staff shall be provided with appropriate training on nursing care for these patients to assure competent care of pre- and post-ECT treatment.

(J) Reference "Recommendations for Treatment, Training, and Privileging: A Task Force Report of the American Psychiatric Association, 2nd ed., 2001".

Effective: 09/20/2010
Promulgated Under: 111.15
Statutory Authority: 5119.01 , 5122.271 , 5122.29
Rule Amplifies: 5119.01 , 5122.271 , 5122.29
Prior Effective Dates: 3-27-1978, 7-1-1980, 1-27-1984, 8-1-1998, 12-1-2000, 12-9-2002

5122-3-05 Competency to stand trial assessment and restoration services for serious youthful offenders (SYOs).

(A) Purpose and background

(1) The purpose of this rule shall be to establish guidelines for competency assessment and restoration treatment of serious youthful offenders (SYOs). Pursuant to section 2152.13 of the Revised Code, effective January 1, 2002, SYOs are afforded all the rights a person who is criminally prosecuted would have if the crime were committed by an adult. This includes the right to be competent to stand trial and utilization of the procedure outlined in Chapter 2945. of the Revised Code, related to competency to stand trial.

(2) Placement/treatment of young children on adult units raises fundamental concerns about the safety and effectiveness of treatment, since ODMH only operates adult inpatient facilities. Treatment of children/adolescents must consider the child's developmental needs and mental status in order to be safe and effective. This rule establishes separate and distinct procedures and guidelines for competency assessment and restoration of children/adolescents. This rule will provide procedures for handling potential referrals from the juvenile courts in Ohio to ODMH facilities. Substantial precedent and common sense support the separation of children from adults in inpatient settings. Prior to the closure of ODMH children's hospitals, in accordance with section 5119.03 of the Revised Code, the department operated separate institutions for children and adults. ODMH private psychiatric hospital licensure rules require that children and adult beds be separate, except for certain emergency admissions of brief periods (forty-eight to seventy-two hours) for older adolescents, aged fifteen through seventeen.

Under this rule, seventeen year olds may be admitted and treated in an adult bed if the person is functioning as an adult in such areas as employment, family, or marriage, or if the diagnosis or problem is such that treatment is warranted in an adult bed.

National professional guidelines clearly recognize that children and adolescents younger than fourteen should be admitted only to programs that are designed for youth and physically distinct from adult psychiatric inpatient programs. Adolescents sixteen and older may be admitted to adult units for valid clinical reasons, but should be treated in a program designed to meet their specific needs. Children and adolescent programs should address the youth's developmental needs including those for education and age-appropriate social interaction.

(B) Definitions

The following definition shall apply to this rule in addition to or in place of those appearing in rule 5122-1-01 of the Administrative Code:

"Serious youthful offender" and "SYO" have the same meaning as in division (X) of section 2152.02 of the Revised Code, i.e., a person who is eligible for a mandatory SYO or discretionary SYO, but who is not transferred to adult court under a mandatory or discretionary transfer.

(C) General guidelines

(1) Young children (under age fourteen years) and younger adolescents (ages fourteen to fifteen) should not be placed in an ODMH regional psychiatric hospital (RPH) because adult facilities are not designed or staffed to provide age-appropriate services for youth. Additionally, because interaction with adult patients on these units may be problematic, these children should be placed in an age-appropriate inpatient psychiatric unit for children or a community residential treatment facility that would specifically meet their individual needs. Older immature adolescents and those not medically cleared for admission to an adult facility should also be treated in these types of settings

(2) Older adolescents (ages sixteen to seventeen) and some younger adolescents (ages fourteen to fifteen) in limited exceptional cases, may be admitted to adult units for valid clinical reasons but should be treated in an individualized program designed to meet their specific needs.

(D) Procedures for admission of adolescents to ODMH RPH inpatient units. Prior to such admissions for competency restoration services, the RPH chief clinical officer shall assure the following:

(1) The child must be medically assessed as appropriate for admission to an adult inpatient unit by a board-eligible or board-certified child psychiatrist with documented specialized training and experience in working with adolescents and their families in an inpatient treatment program;

(2) Other available less restrictive treatment resources (e.g., residential treatment, intensive outpatient), must have been considered and determined to not be available or not appropriate to meet the youth's mental health and safety needs; and

(3) An individual plan of care must be developed by a child/adolescent psychiatrist or in consultation with a child/adolescent psychiatrist to meet the adolescent's restoration to competency needs including the developmental, educational, safety, and environmental needs.

(E) Guidelines for adolescent competency to stand trial restoration treatment services provided in the RPH.

(1) Treatment for the adolescent should be supervised by a child/adolescent psychiatrist or in consultation with a child/adolescent psychiatrist;

(2) All relevant components of the competency to stand trial restoration service are to be adjusted to meet the adolescent's developmental, educational, safety, and environmental needs;

(3) Upon admission, an objective competency assessment should be performed.

Standardized competency assessment tools may be utilized;

(4) Multi-modal, experiential competency restoration educational experiences, (e.g., discussions, reading, video, role playing or mock trial), may be utilized;

(5) An educational component should be included regarding the criminal charges, severity of charges, sentencing, pleas, plea bargaining, roles of the courtroom personnel, adversarial nature of the trial process and evaluating evidence;

(6) Periodic reassessment of competency should be made regarding the adolescent's progress toward restoration to competence; and

(7) Medication treatment may be needed in order for restoration to competence to occur.

Effective: 01/24/2011
Promulgated Under: 111.15
Statutory Authority: 5119.01
Rule Amplifies: 2152.13
Prior Effective Dates: 1-2-2002 (Emer.), 4/3/02

5122-3-09 Regional psychiatric hospital tuberculosis control program.

(A) The purpose of this rule shall be to establish a policy that will conform to current medically recommended measures for the control of tuberculosis in all regional psychiatric hospitals under the managing responsibility of the department of mental health (ODMH).

(B) The following definitions shall apply to this rule in addition to or in place of those appearing in rule 5122-1-01 of the Administrative Code:

(1) "Active tuberculosis disease" means that tuberculosis has been demonstrated by clinical, bacteriological, or radiographic evidence to be present in an individual who has not completed an appropriate course of anti-tuberculosis medication, regardless of the stage of communicability of the tuberculosis, and includes both pulmonary and extrapulmonary tuberculosis.

(2) "Case record" means a specific clinical record maintained at a department operated facility or program which documents the current physical condition and treatment of a patient or an employee who presently has, or has had, tuberculosis.

(3) "Chemoprophylactic therapy" means the treatment applied to prevent development of active disease in an already infected individual.

(4) "Communicable tuberculosis" means active tuberculosis that has been determined, through examination of an individual's respiratory tract cultures, to be in a stage at which it can be transmitted to another individual.

(5) "Community support network (CSN)" means a system of integrated clinical community mental health services designed through the local board, community service network and the department of mental health, collaborating with consumer needs in the forefront.

(6) "Extrapulmonary tuberculosis" means tuberculosis that affects tissue other than the lungs. Extrapulmonary tuberculosis is not communicable.

(7) "Infectious" means capable of transmitting infection. (When persons who have clinically active pulmonary or laryngeal tuberculosis (TB) disease cough or sneeze, they can expel droplets containing mycobacterium tuberculosis into the air).

(8) "Medical advisor" means a designated physician who is available to the regional psychiatric hospital and is responsible for monitoring such clinical activities as the treatment and chemoprophylaxis of both active tuberculosis cases and positive reactors.

(9) "Mycobacterium tuberculosis (TB)" means the organism that causes TB and is sometimes called the tubercle bacillus. It belongs to a group of bacteria called mycobacteria.

(10) "Purified protein derivative (PPD) - tuberculin test" means a skin test used to evaluate the likelihood that a person is infected with mycobacterial tuberculosis.

(11) "Pulmonary tuberculosis" means tuberculosis that affects the lungs.

(12) "Qualified medical provider" means any general hospital or clinic, private physician, health maintenance organization and/or preferred provider organization which is duly licensed and/or certified.

(13) "Regional psychiatric hospital" means the five state mental healthcare facilities run by ODMH which represent seven hospital sites across the state of Ohio. A broad array of mental health services are provided in acute and long-term environments and to community support networks (CSN).

(14) "Tuberculosis control officer" means the individual assigned responsibility by the chief executive officer for designing, implementing, evaluating and maintaining the tuberculosis control program of the regional psychiatric hospital.

(15) "Tuberculosis infection" means means the condition of a person who is purified protein derivative (PPD) mantoux positive, but whose x-ray changes are compatible with tuberculosis which is stable in serial x-rays, and whose bacteriology study results are negative whether the situation has been previously known or not. 5122-3-09 2

(C) Procedure

(1) Every patient upon admission to the regional behavioral hospital shall receive tuberculosis testing with informed consent unless documentation is available that tuberculosis testing has been performed by a qualified medical provider within the past six months, or more frequently based on exposure and risk factors, or the patient refuses to be tested. If the patient refuses to be tested or if prior positive or allergic, he/she shall be referred to the tuberculosis control officer to determine if he/she meets the criteria defined in paragraph (C)(5) of this rule.

(2) All newly hired employees shall be required to submit to tuberculosis screening as a condition precedent to starting work unless documentation is provided that the employee has received tuberculosis testing by a qualified medical provider within the past twelve months, or more frequently based on exposure and risk factors or the person is allergic, or a prior positive reactor.

(3) At least annually or more frequently based on exposure and risk factors, all patients and employees at each regional psychiatric hospital and patients and employees in CSN programs operated by the department shall be screened for tuberculosis. In those situations where employees are working in a community based program or CSN not operated directly by the department, employees will be screened for tuberculosis by the community based program facility. Where such screening is not offered, employees shall be screened for tuberculosis by the department.

(4) Any employee who is symptomatic of tuberculosis disease process or is found to have active tuberculosis shall be removed from active duty and referred for medical care and not return to work until he/she is no longer infectious and is fit for duty.

(5) Any patient with symptoms of active tuberculosis (e.g., blood in sputum, night sweats, weight loss), or has had significant exposure to tuberculosis, or is found to have an active tuberculosis disease case shall be immediately referred to the tuberculosis control officer for evaluation, counseling, education and referral for appropriate treatment. This may include isolation and evaluation for court-ordered testing and treatment.

(6) Each regional psychiatric hospital shall establish a written tuberculosis control program that satisfies the current center for disease control and prevention (CDC) guidelines, OSHA regulations, and is consistent with the 5122-3-09 3 current department tuberculosis control plan.

(7) Pregnant females are to be screened for TB. A pregnant female may be excluded from screening only with written permission from her medical provider.

(8) Volunteers who provide ten or more hours of service in a thirty-day period shall be subject to the TB testing requirements articulated above.

(D) Leadership and implementation of tuberculosis control program

(1) Leadership

(a) The chief executive officer (CEO) of each regional psychiatric hospital, in consultation with the regional psychiatric hospital's chief clinical officer (CCO), shall appoint a physician to serve as a medical advisor for the tuberculosis control program.

(b) The CEO of each regional psychiatric hospital BHO, in consultation with the CCO, shall appoint a registered nurse or a physician to serve as the tuberculosis control officer.

(c) In the event that the medical advisor and the tuberculosis control officer are unavailable, the CEO shall defer to the CCO for advice.

(2) Implementation

(a) The tuberculosis control officer shall become thoroughly acquainted with the department's tuberculosis control program as outlined in this rule and, with the assistance from the medical advisor as needed, shall be responsible for the following:

(i) Directing annual tuberculosis screening evaluation of all patients and all employees, utilizing appropriate screening and methods;

(ii) Verifying that treatment for patients and employees who have been confirmed to have active tuberculosis disease has been accomplished;

(iii) Monitor the continued prescribing of chemoprophylactic therapy 5122-3-09 4 for patients and employees who are newly positive skin test convertors;

(iv) Developing and distributing continuing education materials and tuberculosis screening questionnaires for use by patients and employees who fail to submit to initial and/or annual tuberculosis screening opportunities;

(v) Ensuring that appropriate measures are taken to isolate and treat active tuberculosis disease in the regional psychiatric hospital or, if adequate treatment is not available, arranging to transfer patients to hospitals where appropriate treatment can be given;

(vi) Directing the follow-up program for patients and employees with old, inactive tuberculosis disease, ensuring that the recommended x-rays and bacteriological evaluations are completed;

(vii) Establishing and maintaining up-to-date case records of all patients and employees who have or have had tuberculosis, and submitting reports to ODMH central office as required; and

(viii) Assuring that required reports are completed and forwarded to appropriate staff and the proper agencies (e.g., local health department, the CDC, etc.).

Effective: 06/13/2009
Promulgated Under: 111.15
Statutory Authority: 111.15 , 5119.01 , 5119.07
Rule Amplifies: 5119.01
Prior Effective Dates: 11-16-1978, 7-1-1980, 3-10-2000, 7/15/02

5122-3-12 Duty to protect.

(A) The purpose of this policy is to implement the duty to protect requirements per section 2305.51 of the Revised Code.

(B) This policy shall apply to all mental health professionals employed or contracted by Ohio department of mental health hospitals.

(C) Definitions:

(1) "Independently-licensed mental health professional" means psychiatrists, psychologists, social workers, counselors and clinical nurse specialists licensed to independently provide mental health services.

(2) "Knowledgeable person" means any person who has reason to believe that a patient has the intent and ability to carry out an explicit threat of inflicting imminent and serious physical harm to a clearly identifiable potential victim(s), who is either an immediate family member of the patient, an employee of the hospital, or an individual who, otherwise, personally knows the patient.

(3) "Mental health professional" means any individual who is licensed, certified or registered under the Revised Code, or otherwise authorized in this state, to provide mental health services.

(D) Procedures:

(1) Any mental health professional to whom an explicit threat of serious physical harm to another person or persons or identifiable structure is made, or who is made aware by a knowledgeable person of an explicit threat made by a patient, will initiate the duty to protect process.

(2) Any explicit threat by a patient shall be promptly communicated by the mental health professional who heard the threat or was made aware of the threat, to a registered nurse or psychiatrist on the patient's treatment team. The treatment team shall determine, based on the patient's history and current condition, whether the threat represents a credible danger to others.

(a) If the treatment team does not consider the threat to be a credible danger to others, this decision and the reason for this determination shall be documented in the medical record.

(b) If the treatment team considers the threat to be a credible danger, the threat shall be reported promptly by the treatment team to the chief clinical officer or designee of the hospital.

(3) The chief clinical officer or designee of the hospital shall assign an independently-licensed mental health professional to conduct a face-to-face evaluation with the patient as soon as possible after receiving notification of the threat, but no longer than two working days, in order to give a second opinion risk assessment of the threat.

(4) If the independently-licensed mental health professional determines that the threat does not meet the threshold requiring discharge of the duty to protect (e.g., threat is not imminent), this assessment should be documented on a form authorized by the regional psychiatric hospital (RPH) or in a progress note in the medical record.

(a) Each RPH shall establish policies and procedures that assure patient re-evaluation occurs prior to the patient being discharged or receiving unsupervised movement, including placing a "Duty to Protect" sticker on the patient's chart and adding a "Duty to Protect" problem on the treatment plan. (See Appendix 1 [DMH-0040a] for "Duty to Protect Tracking Form" which may be used by the RPH to monitor procedure compliance).

(b) The independently-licensed mental health professional shall record, in a progress note or indicate on a RPH form, that the patient does not have either the intent or ability to carry out the threat and record the reason(s) for this conclusion.

(c) Other clinical recommendations may be considered for this patient and should be documented as appropriate in the medical record.

(5) If the independently-licensed mental health professional determines that there is an explicit threat of imminent and serious physical harm and there is reason to believe the patient has the intent and ability to carry out the threat, the independently-licensed mental health professional completing the RPH form or documenting this assessment in a progress note in the medical record, must address each of the relevant options to discharge the duty to protect in section 2305.51 of the Revised Code and indicate the reason(s) each was, or was not, chosen.

(a) Since the patient in these instances is already hospitalized, the relevant options for further action under section 2305.51 of the Revised Code for discharging the duty to protect are as follows:

(i) Establishing and undertaking a treatment plan that is reasonably calculated to eliminate the possibility that the patient will carry out the threat (having performed this second opinion risk assessment consultation); and

(ii) Communicating to a law enforcement agency either where the victim or patient resides and, if feasible, communicating with the potential victim(s) and/or guardian(s) about the threat;

(b) If the option chosen by the independently-licensed mental health professional is to warn the potential victim(s) and appropriate law enforcement agency, the independently-licensed mental health professional shall notify the chief clinical officer (or designee) who will designate the person to give the warning;

(i) The information about who was warned, what information was shared, and the time of the warning shall be documented on the RPH form (Appendix 2 [DMH-0040]) or in the progress note in the medical record; and

(ii) Information shared should be restricted to the name and the description of the patient, the nature of the threat, and the name of potential victim(s) and/or potential structure threatened.

(6) Progress notes in the medical record should reflect any contacts with consultants, chief clinical officer (or designee), or the patient's treatment team as appropriate.

(7) The RPH authorized form, or a copy of the progress notes about the threat should be filed in the legal section of the medical record. A copy should be forwarded to the legal assurance administrator of the hospital.

(8) If the threat is considered to be serious but not imminent, and the independently-licensed mental health professional believes the threat should be re-evaluated closer to unsupervised movement, conditional release or discharge of the patient, the independently-licensed mental health professional will contact the treatment team social worker who will affix or cause to be affixed, a prominent sticker on the front of the patient's medical record noting a "Duty to Protectr" and add a "Duty to Protect" problem to the treatment plan.

(9) When a "Duty to Protect" sticker is affixed to the medical record and a problem is added to the treatment plan, prior to unsupervised movement, conditional release or discharge, the treatment team social worker will notify the chief clinical officer (or designee) who will assign an independently-licensed mental health professional to conduct a face-to-face re-evaluation of the presence or absence of the threat, and if present, the credibility of the threat.

(10) If a patient with a "Duty to Protect" problem goes AWOL from a RPH, the treatment team (or on evenings, weekends, and holidays, the nurse manager) shall promptly give a recommendation to the chief clinical officer regarding warning law enforcement and, if feasible, potential victims in the community.

(11) In all re-evaluations, the independently-licensed mental health professional should locate the original RPH form or progress notes about the threat in the medical record or in the file of the legal assurance administrator.

(a) After the face-to-face re-evaluation, a new RPH authorized form or medical record progress note shall be completed and filed in the legal section of the medical record with a copy to the legal assurance administrator.

(i) If no active serious threat is present, this should be noted on the RPH form or in a progress note and no further formal action is necessary;

(ii) If an active, serious, and imminent threat remains, this should be documented on the RPH form or in a progress note and the actions identified in paragraphs (D)(5) to (D)(7) of this rule should be followed. In addition, the independently-licensed mental health professional shall promptly notify the treatment team for appropriate action regarding the pending unsupervised movement, conditional release, or discharge.

Click to view Appendix

Click to view Appendix

Effective: 08/05/2011
Promulgated Under: 111.15
Statutory Authority: 111.15 , 5119.01
Rule Amplifies: 2305.51
Prior Effective Dates: 1-1-2006

5122-3-13 Regional psychiatric hospital (RPH) incident reporting rule.

(A) Purpose.

The purpose of this rule is to establish standards and procedures to ensure that prompt and accurate reporting; immediate evaluation; implementation of corrective and remedial action; and preventative measures take place with the occurrence of each incident. Effective incident reporting provides each hospital with individual and cumulative incident report data to find problem areas and implement corrective measures designed to prevent recurrence and manage risk. Analysis of this data can reveal system issues and problems in need of corrective action.

(B) Applicability.

The provisions of this rule shall be applicable to all hospital inpatient and community support network (CSN) programs under the managing responsibility of the department. Subject to this rule, all occurrences during an inpatient stay or within thirty days of discharge must be recorded in the patient care system regardless of other reporting requirements (i.e., the joint commission, department of health, etc.).

(C) Definitions.

The following definitions shall apply to this rule in addition to those appearing in rule 5122-1-01 of the Administrative Code:

(1) "Absent without leave" or "AWOL" means a patient has breached the secure perimeter of the hospital without permission, has eloped during, or has not returned from an authorized absence from the facility. The reporting of AWOLs is determined in paragraph (D)(6) of this rule.

(2) "Abuse" means any act or absence of action caused by an employee inconsistent with rights which results, or could result in physical injury to a patient; any act which constitutes sexual activity, as defined under Chapter 2907. of the Revised Code, where such activity would constitute an offense against a client under that chapter; insulting or coarse language or gestures directed toward a client which subjects the client to humiliation or degradation; or depriving a patient of real or personal property by fraudulent or illegal means.

(a) There are five sub-types of abuse: physical, verbal, sexual, neglect, and defraud. If there are multiple sub-types to an incident, only select the most severe sub-type when recording an incident. For example, if a patient alleges both physical and verbal abuse, code the allegation as "physical." All incidents of abuse are "major."

(b) When recording "alleged abuse," the staff person alleged to have committed abuse shall be coded as "perpetrator" and the patient as "victim."

(c) Frequent allegations of sexual abuse shall be investigated, but need not be reported as incidents unless such allegations are founded. However, record of the allegations and subsequent investigations shall be recorded in the clinical record and addressed in the treatment plan.

(3) "Accident" means any incident that results from an unintentional occurrence.

(a) There may or may not be injuries associated with an accident. When an injury or injuries occur, the following codes shall be utilized to classify the accident:

(i) Patient or staff injury resulting from a restraint which requires more than first-aid is a "major" incident.

(ii) Patient or staff injury needing no treatment or first-aid is a "minor" incident.

(iii) Patient or staff injuries needing medical treatment may be "minor" or "major," depending on the severity.

(b) Unexpected hospitalization (including observation) resulting from an accident is a "major" incident.

(c) All "accident/falls" and "accident/choking on food" with or without injuries shall be considered as reportable incidents as defined in paragraph (C)(20) of this rule.

(d) When recording an "accident," staff shall indicate whether the accident was observed or not observed by staff.

(4) "Assault" means to knowingly or recklessly cause or attempt to cause physical harm to another. Assault is distinct from a threat, in that assault is an actual attempt to cause physical harm instead of a statement alluding to such action. An allegation of an employee assaulting a patient shall be reported as "alleged abuse." Assault includes all types of physical aggression except when further defined under "abuse."

Assault has four sub-types: sexual, physical, weapon, and other.

(a) All physical assaults resulting in the need for admission to a general hospital shall be classified as "major" incidents. Physical assaults requiring more than first-aid and less than admission to a general hospital shall be classified as "major" or "minor" at the discretion of the CEO. Physical assaults requiring less than first-aid shall be classified as "minor" incidents.

(b) All weapon assaults shall be classified as "major" incidents.

(c) An allegation of sexual assault that involves non-consensual sexual conduct shall be further classified as rape. A rape allegation shall be reported as a "major" incident.

(d) Frequent allegations of sexual assault resulting from fixed delusions shall be investigated, but need not be reported as incidents unless the allegations are founded. However, record of such allegations and subsequent investigation shall be recorded in the clinical record and addressed in the treatment plan.

(e) When two persons are fighting and it is unclear or unknown who started the fight, both persons shall be coded as "perpetrators." Otherwise, individuals involved shall be coded either "perpetrator" or "victim" as appropriate. Of the persons involved, the one with the highest level of injury determines the incident status ("major" or "minor") for the whole incident.

(5) "Attempted suicide" means an unsuccessful attempt to end one's own life with a finding of intent as determined by a clinician.

(a) Attempted suicide is a "major" incident.

(b) Suicidal thoughts should not be reported as incidents but should be documented in the patient's chart.

(c) When recording attempted suicide, the patient should be coded as "victim."

(6) "Chief clinical officer" or "CCO" means the medical director of an RPH as defined in division (K) of section 5122.01 of the Revised Code.

(7) "Chief executive officer" or "CEO" means an individual who directs and oversees the operation of an RPH.

(8) "Confirmed abuse/neglect" means an allegation of abuse or neglect has been proven to have occurred.

(9) "Contaminated/unknown sharps injury" (i.e., needle sticks, etc.) means the injury of any person involved. Those at greater than first-aid may be considered a "major" incident depending upon severity, and all others are "minor" incidents.

(10) "Contraband and restricted/controlled items" means those items that are not permitted on state property pursuant to law or hospital policy. The following shall be considered contraband:

(a) All weapons or potential weapons including, but not limited to, guns, knives, electronic control devises such as tasers and stun guns, defensive aerosol sprays, ammunition and explosives;

(i) If weapons or potential weapons are brought onto or found on state property, the incident shall be reported as "major." Firearms or electronic control devices in the possession of peace officers shall not be reported unless such items are brought onto patient units;

(ii) Discharge of a weapon or electronic control device on RPH property is considered a "major" incident;

(iii) Intoxicating beverages and illicit drugs including, but not limited to, non-prescribed prescription drugs and illegal drugs; and

(iv) Stolen articles.

(b) If police arrest an individual for possession of contraband or restricted/controlled items, the incident shall be considered "major." Possession of other contraband and restricted/controlled items shall be considered "minor" incidents unless stated otherwise in this rule.

(11) "Critical major incident" means an event for which there is a need to immediately advise the deputy director of hospital services, the ODMH medical director and the ODMH director of the situation. These include, but are not limited to, death; rape; injury which may result in permanent loss of functioning; AWOL of a forensic patient; AWOL of a patient whose life may be endangered because of weather, illness, poor judgment, or other conditions; power failure which is not quickly resolved; loss or exposure of personal health information (PHI); fire (at the discretion of the CEO); and all sentinel events as defined in rule 5122-2-25 of the Administrative Code.

(12) "Death" means the death of a patient while on hospital rolls or within thirty days of discharge.

(a) If type of death is unknown, select "pending."

(b) The person who dies should always be coded as the "victim."

(c) Death is a "major" incident if the person died while an inpatient, or within thirty days of discharge. If death was a result of suicide or other non-natural causes while an inpatient, or within thirty days of discharge, it is a "critical major" incident.

(13) "Equipment or utility failure or malfunction" means any unplanned malfunction or failure of essential utility systems including, but not limited to: electrical power distribution; plumbing (water and waste disposal); natural gas; emergency power (generators); elevators; air-conditioning (HVAC); boilers; and communications or patient care/medical equipment (including ADMs) that do not function according to their designed purpose and could result in a potentially unsafe situation for patients, staff and visitors.

(a) Equipment or utility failure which requires a repair in excess of one thousand dollars; having a significant impact on the operation of the RPH (as determined by the CEO or designee); or requiring the evacuation of a building shall be coded as a "major" incident.

(b) Other instances shall be considered "minor" incidents.

(14) "Fire" means the burning of a solid, liquid, or gas that must be extinguished to prevent the spread of the fire or smoke from endangering patients, staff, visitors, or buildings.

(a) Any fire that results in an injury, a fire department response to extinguish, or an evacuation of a building is a "major" incident.

(b) Other types of fires shall be considered as "minor" incidents.

(15) "Illicit use or possession of drugs or alcohol" means that a person is suspected of or actually under the influence of alcohol or drugs.

(a) If the person is arrested, the incident is "major."

(b) All other incidents shall be considered "minor."

(16) "Illness or medical emergency" means physical illnesses such as infections, kidney problems, cardiac emergencies, etc., which require treatment outside the RPH.

(a) Unexpected hospitalization (including observation) due to illness or medical emergency is a "major" incident. However, if a person is examined and treated and sent back to the RPH without being admitted, the incident shall be considered "minor."

(b) Scheduled trips or admissions to other medical facilities for planned medical or surgical interventions are not reported as illnesses or medical emergencies.

(17) "Inappropriate sexual behavior" means public masturbation, sexual touching, inappropriate kissing, making repeated or targeted inappropriate sexual comments, sexual advances, and attempts to have or to have had sexual intercourse by any person. Non-consensual sexual intercourse is classified as "rape."

(a) If a staff person is involved as the perpetrator against staff, visitors, or others, the incident is "major."

(b) Staff-to-patient inappropriate sexual behavior is considered "patient abuse."

(c) If a patient, visitor, or other is involved as the perpetrator, the incident may be considered "major" at the discretion of the CEO/designee.

(18) "Incident" means any occurrence which is not consistent with the routine care of a patient, the routine services provided by the hospital, or the routine standard of care for the hospital. Incidents may involve patients, employees, visitors, and other persons as further specified in this rule. Incidents involving patients are not restricted to those occurrences on the hospital's premises. Also included is any patient who is on the rolls of the hospital and is involved in an incident while away from the hospital.

(19) "Injury to staff while restraining a patient" means injury to any employee while in the process of restraining a patient, or while the patient is in seclusion and restraint. This category includes any injuries sustained in an accident that occurred as a direct result of responding to a restraint event.

(a) All injuries requiring more than first-aid as a result of restraint are "major."

(b) Injuries needing no treatment or first-aid are "minor."

(20) "Major incident" means an occurrence severe enough to warrant special categorization for purposes of reporting and includes the following:

(a) Injury or illness which results in admission to a general hospital;

(b) Attempted suicide;

(c) AWOL as further defined in paragraph (D)(6) of this rule;

(d) Property damage, loss, or theft valued at more than one thousand five hundred dollars;

(e) Injury occurring during the course of restraint that requires more than first-aid;

(f) Medication errors of level five or six;

(g) Abuse;

(h) Assault resulting in admission to a general hospital; or rape; or weapon assault;

(i) Death;

(j) Weapons or potential weapons brought onto or found on state property;

(k) Discharge of a weapon or electronic control device on RPH property;

(l) Arrest of an individual for possession of contraband or restricted/controlled items;

(m) Inappropriate sexual behavior by a staff person against staff, visitors, or others; or neglect of patients;

(n) Threats toward specific public officials; bomb threats that require the evacuation of a building; or threats sufficient to warrant a warning as found in section 2305.51 of the Revised Code, and rule 5122-3-12 of the Administrative Code ("Duty to protect");

(o) Missing medication which requires a police investigation;

(p) Any incident requiring an outside police investigation;

(q) Unauthorized use of restraint;

(r) Any fire resulting in an injury, a fire department response to extinguish, or an evacuation of a building;

(s) Illicit use of alcohol or drugs resulting in an arrest;

(t) Anything judged by the CEO as being a "major" incident;

(u) Equipment or utility failure which requires a repair in excess of one thousand dollars; has a significant impact on the operation of the RPH (as determined by the CEO or designee); or requires the evacuation of a building; or

(v) Any violation where an outside agency is notified, or for a potential violation of existing workplace violence policy(ies) of the department.

(21) "Medication error" (also called "medication variance") means any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to: professional practice; health care products; procedures and systems, including all aspects of prescribing (i.e., order communication, product labeling, packaging, nomenclature, compounding and dispensing, distribution, administration, education, monitoring and use). Medication errors are assigned a severity level based on ODMH policy MD-03, "Medication Errors."

(a) All medical errors of level five or six are "major" incidents.

(b) Medication errors of level zero through four are not considered incidents but should be documented pursuant to ODMH policy MD-03, "Medication Errors."

(22) "Minor incident" means those types of occurrences which do not appear to be severe or detrimental to the best interests of the patient, department, RPH or personnel.

(23) "Missing medication" means an incident where medication is unaccounted for, such as when a patient returns from authorized leave without the medication with which they were provided; or when controlled medications are missing from the ADM machines after the count has been reconciled.

(a) All incidents requiring police investigation are "major."

(b) All other incidents are "minor."

(24) "Neglect" is defined in rule 5122-3-14 of the Administrative Code as "a purposeful or negligent disregard of duty imposed on an employee by statute, rule, RPH policy, position description, or professional standard and owed to a client by that employee." Responses to allegation of abuse or neglect shall be consistent with the requirements of rule 5122-3-14 of the Administrative Code.

(25) "Office of quality assurance and improvement" means the office of quality assurance and improvement of ODMH.

(26) "Other" means the classification of an incident when no other incident type appropriately describes an incident.

(27) "Patient care system" or "PCS" means the official secure centralized ODMH automated database where patient demographic and related information is maintained.

(28) "Policy violation (staff only)" means any act where staff has perpetrated an incident and no other incident type appropriately describes the incident. When recording this type of incident, one must record the policy violated as well.

(a) Any violations where an outside agency is notified or the workplace violence policy potentially has been violated are "major."

(b) All other incidents may be "major" or "minor" incidents depending upon the severity of the incident as determined by the CEO or designee.

(29) "Program" means any service provided by ODMH employees.

(30) "Property damage" means accidental damage to property, but may also include damage due to negligence or intentional acts by entities outside the hospital. For example, a falling tree that hits a car; damage due to patient behavior; and vandalism constitute property damage.

(a) Property damage greater than one thousand five hundred dollars or that has a significant impact on the operation of the organization (as determined by the CEO or designee), or that requires the evacuation of a building are "major" incidents.

(b) All other property damage incidents are "minor."

(31) "Property loss" means accidental or negligent loss of department or state of Ohio property. If the value of the property is greater than one thousand five hundred dollars, or involves a loss of protected health information, the incident is "major." All other property loss incidents are "minor."

(32) "Self-injurious behavior" means an act of self-induced bodily harm that is not intended to kill oneself.

(a) Injury of any person involved at greater than first-aid should be considered "major."

(b) Injuries needing only first-aid are "minor" incidents.

(33) "Sentinel event" means an event defined in rule 5122-2-25 of the Administrative Code.

(34) "Theft" means the taking of another person's property without the person's permission or consent. Allegations of theft of patient property by employees should be reported as "major" under "alleged patient abuse."

(a) Any theft of property which constitutes a substantial value as determined by the CEO or designee, in consultation with the department's security consultant, is a "major" incident.

(b) The theft of property which is not considered of substantial value is a "minor" incident.

(35) "Threat" means behavior meant to intimidate a person such that there is a reasonable fear of bodily harm through the use of threatening words and/or conduct without use of a weapon or actual physical attack. Threats include, but are not limited to, bomb threats, threats of aggression or violence, threats against public officials, spousal threats thought to be serious, stalking, and menacing.

(a) Threats towards specific public officials, bomb threats that require the evacuation of a building, or threats sufficient to warrant a warning as found in section 2305.51 of the Revised Code and rule 5122-3-12 of the Administrative Code ("Duty to Protect") are "major" incidents.

(b) Others are "minor" incidents.

(36) "Unauthorized movement" or "UM" means any incident where the patient has been absent from a location, within the facility defined by the patient's privilege status regardless of the patient's leave or legal status. A patient should be considered UM if the patient has not been accounted for when expected to be present. Implicit in this definition is the notion that the patient has been informed of the limits placed on her/his location or movement prior to the UM incident. All UM incidents are considered "minor."

(37) "Unauthorized use of restraint" means instances where hospital policies and procedures were not followed in authorizing the use of seclusion or restraint. All instances are considered "major" incidents.

(38) "Unfounded abuse/neglect" means that an allegation of abuse or neglect was not supported by evidence upon investigation.

(39) "Unproven abuse/neglect" means it could not be proven that the incident did or did not happen. There may have been conflicting or inadequate evidence to either prove or disprove that the abuse/neglect occurred.

(D) Reporting of incidents.

(1) All incidents shall be documented and reported in accordance with the provisions of this rule and on the forms and database prescribed by the department.

(2) Investigation of incidents.

(a) The CEO shall develop an investigative procedure to be followed by employees in response to the occurrence of all incidents.

(b) Based on the severity of the occurrence, some incidents shall be reported to central office as defined in paragraphs (D)(4) to (D)(7) of this rule.

(3) Incidents classified as "major";

(a) Major incidents shall include, but not be limited to the following:

(i) All sentinel events;

(ii) All deaths. In addition, the following deaths shall be reported immediately to the coroner and the Ohio state highway patrol:

(a) Suicide;

(b) Accidental death regardless of cause;

(c) Apparent or possible homicide; and

(d)Any suspicious or unusual death.

(iii) Events determined by the CEO or designee and/or CCO or designee that require the immediate investigation by the local law enforcement agency and/or the Ohio state highway patrol. Examples include:

(a) Serious injury caused by another person, whether another patient, employee, or any other person;

(b) Alleged criminal act of an employee committed on hospital grounds or while performing occupational duties off-grounds which may result in a felony or misdemeanor charge;

(c) Alleged criminal act of a patient which may result in a felony or misdemeanor charge; and

(d)Alleged criminal act on RPH grounds by person other than an employee or patient which may result in a felony or misdemeanor charge.

(iv) Severe weather conditions resulting in the disruption of the normal operation, safety, and/or security of the RPH; and

(v) All "major" incident types as further defined in paragraph (C)(20) of this rule.

(4) General reporting requirements.

(a) The employee who discovers or witnesses an incident, or to whom an incident is reported, is responsible for documenting the incident, cooperating in the investigation, and providing the investigating officer or staff with a complete statement or statements as needed.

(b) The incident notification report (DMH-ADM-005a or DMH-CSN-008, as appropriate) required by ODMH shall be completed for each incident. Each CSN also has additional reporting responsibilities utilizing form DMH-0484/LIC-015.

(c) Facts regarding the incident shall be reported in writing. No unsubstantiated conclusions, opinions, hearsay, assumptions, or accusations shall be included in the incident report.

(d) The incident report shall not be filed, nor references to an incident report made, in the patient medical record. However, those events which have a direct medical or clinical effect on the patient should be recorded in the patient medical record. The incident report shall be maintained in an administrative file. The CEO shall utilize a procedure for the filing and internal management of incident reports.

(e) Incident reports shall be maintained in a confidential manner and be accessible only to authorized employees except by consent of the CEO in consultation with the department's legal office.

(i) The Ohio state highway patrol may have access only to the incident notification report form (DMH-ADM-005a) or the CSN incident notification report form (DMH-CSN-008) upon request.

(ii) If requested, the local mental health board only shall have access to information on the incident notification report form (DMH-ADM-005a) or the CSN incident notification report form (DMH-CSN-008).

(f) The CEO shall designate a person to be responsible for notifying the parents, spouse, legal guardian, or legal custodian of a patient about the occurrence of an incident involving a patient. This disclosure shall require the consent of the patient except if the patient is deceased, AWOL, or unconscious.

(g) The CEO shall develop a policy that determines which hospital staff are to be notified of the occurrence of incidents.

(5) Immediate reporting to central office.

(a) Utilizing the telephone call-in procedure defined in ODMH policy I-05, ("Central Office Administrative Officer of the Day"), the CEO or designee shall report at all times, the occurrence of any of the following major incidents to the deputy director of hospital services.

(i) All deaths;

(ii) AWOL of a patient as defined in paragraph (D)(6) of this rule;

(iii) Fires, as defined in paragraph (C)(14) of this rule;

(iv) Equipment or utility failure or malfunction as previously defined in paragraph (C)(13) of this rule that may result in significant potential danger, as determined by the CEO or designee, to staff and/or patients (i.e., loss of fire alarm or suppression systems, telephone service, emergency generator, or water/sanitary systems);

(v) Other incidents, as determined by the CEO or designee, that are critical in nature and may result in significant danger to staff and/or patients (i.e., a hostage situation, a flood, severe weather conditions, bizarre or unusual crimes or events); and

(vi) Any incident, as determined by the CEO or designee, that would likely result in news media coverage.

(b) All incidents that involve a morbidity, mortality, or reviewable sentinel event, as defined in rule 5122-2-25 of the Administrative Code, "Morbidity, mortality, and sentinel event," shall be reported to the ODMH medical director or designee by the hospital CCO or designee via telephone or email.

(c) For incidents listed in paragraphs (D)(5)(a) and (D)(5)(b) of this rule which occur between five p.m. and eight a.m. Monday through Friday and all day on weekends and holidays, the CEO or designee shall contact the ODMH administrator on duty pursuant to ODMH policy I-05, ("Central Office Administrative Officer of the Day").

(6) AWOL reporting procedure.

(a) AWOLs are reportable to central office as either "minor," "major," or "critical major" incidents. All AWOL data shall be tracked internally by RPH procedures and monitored through quality improvement activities. Incident reports involving AWOLs shall include the time and date the patient eloped, when the patient was returned (or discharged), location where found, and a description of all activity that may have occurred while the patient was AWOL.

(b) AWOL as a "critical major" incident.

The following AWOLs are considered reportable as "critical major" incidents.

(i) AWOL of patients considered at risk to self or others for which, because of their psychiatric history, criminal history, legal status, immigration status, or current psychiatric condition or behavior, there is a need to notify state or federal law enforcement (i.e., Ohio highway patrol, federal marshal's office, FBI, secret service, or homeland security, respectively); or

(ii) Any AWOL not identified in paragraph (D)(6)(b)(i) of this rule that the hospital's CEO, designated AoD or deputy director deems to be reported as such (i.e., imminent threat to self or others, extreme adverse weather conditions, fragile medical status, etc.);

(iii) The RPH CEO or designee shall report an AWOL that is considered to be a critical major incident to the ODMH hospital services deputy director immediately upon discovery. The deputy director may be reached by calling the twin valley behavioral healthcare Columbus switchboard at 614-752-0333. Alternatively, the reporting CEO or designee may contact the deputy director through the cell phone.

(c) AWOL as "major" incident.

When a patient falls under a certain legal status, or meets specific criteria, the incident is reportable as a "major" incident to central office. These incidents fall within the following categories:

(i) Forensic AWOL: all patients with a forensic legal status or tracked as forensic and listed in the following divisions and sections of the Revised Code:

(a) 2945.371(G)(3) - competency evaluation;

(b) 2945.371(G)(4) - sanity evaluation;

(c) 2945.38(B) - IST-R;

(d) 2945.38(H)(4) - IST-U;

(e) 2945.39(A)(2) - IST-U-CJ;

(f) 2945.401 - IST-U-CJ-CR;

(g) 2945.40 - NGRI ;

(h) 2945.402(A) - NGRI-CR;

(i) 2967.22 - parole/probation;

(j) Police hold/capias; or

(k) Jail transfer.

(ii) Risk of harm to self or others: All patients who, in the judgment of the CCO, are the following:

(a) At risk of harming self or others;

(b) Currently held on an emergency certificate under section 5122.10 of the Revised Code;

(c) Adjudicated at risk by a probate court under division (B) of section 5122.01 or division (C) of section 5122.15 of the Revised Code.

(iii) The RPH CEO or designee shall report an AWOL that is considered to be a major incident to the ODMH hospital services deputy director immediately upon discovery. The deputy director may be reached by calling the twin valley behavioral healthcare, Columbus switchboard at 614-752-0333. Alternatively, the reporting CEO or designee may contact the deputy director anytime through the cell phone.

(d) AWOL as a "minor" incident.

An AWOL that does not fall under the classifications described in paragraphs (D)(6)(b) and (D)(6)(c) of this rule shall be considered a "minor" incident, (i.e., a voluntary patient who is not considered at risk to self or others). RPHs shall be responsible for maintaining information about AWOLs classified as "minor" incidents but no telephone reporting to central office is required.

(e) Notice of discharge requirements for forensic patients.

In accordance with division (A) of section 5122.26 of the Revised Code, the RPH CCO may discharge a patient who is under indictment, sentence of imprisonment, or on probation or parole and who has been AWOL for more than thirty days, but shall give written notice of the discharge to the court having criminal jurisdiction over the patient.

(i) Within ODMH RPHs, this statute is applicable to patients in the following forensic categories: NGRI, IST-U, IST-R, IST-U-CJ, parolee/probationer, jail transfer, capias, and patients on conditional release status.

(ii) The RPH shall also notify the ODMH division of legal and regulatory services and the ODMH office of forensic services of the planned discharge of all patients indicated in this section.

(f) Discharge of civil patients.

The CCO of a RPH may discharge any other (civil) patient who has been AWOL for more than fourteen days.

(g) External AWOL reporting requirements.

The RPH CEO is responsible for additional notification to external agencies in certain cases. For external reporting purposes, the CEO is responsible for developing policies for the timely notification of "critical major" and "major" AWOL incidents to the following agencies:

(i) Ohio state highway patrol and local law enforcement regarding information about individuals that the patient has threatened and RPH think could be in danger;

(ii) County prosecutor and local law enforcement agencies (forensic patients) in accordance with ODMH policy I-12, "Apprehension of Forensic Patients who Leave RPH Grounds";

(iii) Victim or victim representatives in accordance with section 2930.16 of the Revised Code;

(iv) The respective community mental health board; and

(v) Federal authorities (i.e., secret service, the federal marshal's office, etc.) as appropriate.

(h) Quality assurance and quality improvement.

The ODMH division of hospital services will monitor RPH AWOL information (incident reports) and data collection and provide aggregate reports, including analysis of trends, on a quarterly basis.

(7) Other procedures for reporting to central office.

(a) All incidents involving a morbidity, mortality, or sentinel event shall be reviewed and reported to the hospital services morbidity and mortality committee as specified by rule 5122-2-25 of the Administrative Code, "Morbidity, mortality, and sentinel event."

(b) All major incidents as defined in paragraphs (D)(3) and (D)(6) of this rule shall be reported within twenty-four hours of the incident to the division of hospital services using the "Incident Notification Report" form (DMH-ADM-005a); and the "Major Incident Report" form (DMH-7034), with copies going to the following as indicated on DMH-7034.

(i) Deputy director of hospital services;

(ii) ODMH medical director;

(iii) Deputy director of legal and regulatory services;

(iv) Chief of the office of legal services;

(v) Staff counsel in the office of legal services;

(vi) ODMH security consultant;

(vii) Assistant deputy director of hospital services; and

(viii) Clinical safety director of hospital services.

(c) For inpatient programs, all major incidents, including those mentioned in paragraph (D)(6) of this rule, shall be reported to the ODMH office of quality assurance and improvement in central office within twenty-four hours of the incident using the automated PCS incident notification report system, and forms DMH-ADM-005a and DMH-7034.

(d) For CSN programs, all major incidents must be reported to the ODMH office of quality assurance and improvement in central office within twenty-four hours of learning of the incident, using the "CSN Incident Notification Report" form (DMH-CSN-008) and DMH-7034. In addition, the CSN, including its licensed residential facilities, shall report outpatient services incidents in accordance with rule 5122-26-13 of the Administrative Code using "Community Mental Health Agency Notification of Incident" form (DMH-LIC-015c); and report residential facility incidents in accordance with rule 5122-30-16 of the Administrative Code using "Residential Facility Notification of Incident" form (DMH-LIC-015r).

(e) The ODMH office of quality assurance and improvement may require such other reports or documents as are necessary to conclude a review of any incident. Data regarding all incidents shall be maintained in a form specified by central office.

(f) Data regarding minor incidents shall be maintained in a form specified by central office using the automated PCS incident notification report system.

(E) Individual and aggregate analysis.

(1) Each hospital and CSN program shall ensure that all incidents are thoroughly and comprehensively reviewed and analyzed:

(a) At the time of submission, on an individual basis, for adequacy of documentation and necessity for follow-up; and

(b) At regular intervals and yearly, on an aggregate basis, to determine rends or patters indicative of a need for corrective action. Such information shall be made available to the ODMH office of quality assurance and improvement.

(2) At regular intervals, the ODMH office of quality assurance and improvement shall supply RPHs with aggregate data on incidents.

(F) Implementation of incident reporting.

The CEO of each RPH shall be responsible for prescribing guidelines for implementation of this rule.

Replaces: 5122-3-13

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Effective: 04/28/2013
Promulgated Under: 111.15
Statutory Authority: 5119.01 , 5119.07 , 5119.43 , 5119.82
Rule Amplifies: 5119.01
Prior Effective Dates: 7/27/1979, 7/1/1980, 2/5/1982, 2/1/2000, 7/15/2000, 9/20/2010

5122-3-14 Abuse/neglect of patients receiving services in regional psychiatric hospitals.

(A) The purpose of this rule shall be to define patient abuse and neglect for persons receiving Ohio department of mental health (ODMH) services in regional psychiatric hospitals (RPHs); to establish policies to prevent abuse and neglect of persons served; to provide guidelines for preventive and corrective measures; and to establish policies and procedures regarding reports and investigations of abuse or neglect of persons served.

(B) The provisions of this rule shall be applicable to all RPHs providing services under the managing responsibility of the department.

(C) Central office employees shall adhere to abuse/neglect policies as determined by the director.

(D) The following definitions shall apply to this rule in addition to or in place of those appearing in rule 5122-1-01 of the Administrative Code:

(1) "Abuse" means any act or absence of action caused by an employee inconsistent with rights which results or could result in physical injury to a client; any act which constitutes sexual activity, as defined under Chapter 2907. of the Revised Code, where such activity would constitute an offense against a client under that chapter; insulting or coarse language or gestures directed toward a client which subjects the client to humiliation or degradation; or depriving a client of real or personal property by fraudulent or illegal means.

(2) "Neglect" means a purposeful or negligent disregard of duty imposed on an employee by statute, rule, RPH policy, position description, or professional standard and owed to a client by that employee.

(E) The department shall promote policies governing patient services that assure protection of persons served from abuse or neglect caused by employees, other persons served, programs, and procedures. Protection shall include informing employees of their duty to prevent and report abuse or neglect of persons served and disciplinary action against employees who have abused or neglected persons served. Volunteers, contractors and other on-grounds non-employees are covered by this rule and are subject to civil/criminal statutes.

(F) Standards.

(1) The standard and quality of care owed to a person served shall be in keeping with current professional standards of care, federal and state laws and regulations, administrative rules of the department, accreditation standards of the joint commission (TJC), as applicable, and instructions, guidelines, or procedures and requirements of court as applicable.

(2) Each employee shall be responsible for safeguarding persons served from abuse or neglect which could be self-inflicted or caused by other persons served, other employees, or other non-hospital persons.

(G) Duties of the chief executive officer (CEO).

(1) The CEO or designee shall adhere to the guidelines established under rule 5122-3-13 of the Administrative Code including, but not limited to, reporting of incidents and providing for investigative and follow-up procedures to ensure that preventive measures take place to reduce the occurrence of future incidents.

(2) The CEO shall be responsible for making every effort to assure the prevention of patient abuse or neglect by the following measures:

(a) Provision of a safe and quality environment for persons served through the physical environment, good maintenance, housekeeping practices, adequate equipment, buildings, grounds, culture, and therapeutic milieu;

(b) Establishment of a policy that requires assigned personnel to know the whereabouts of each person served at all times;

(c) Provision of quality clinical services that meet the individual medical, psychological, personal needs, choices and promotes individual recovery of persons served; and

(d) Periodic determination of trends related to patient abuse or neglect.

(3) The CEO shall be responsible for reporting and investigating procedures for inpatient services as follows:

(a) Requiring the RPH police chief to:

(i) Thoroughly investigate reports of alleged patient abuse or neglect in accordance with rule 5122-7-04 of the Administrative Code, submit a written report on a security report form to the chief CEO or designee within forty-eight hours of the reported incident, and determine if the conduct of the employee is in violation of any standard of care under paragraph (F) of this rule;

(ii) prior to any interviews or conversations regarding the allegation of abuse/neglect, persons served are to be provided any reasonable accommodation, close-captioned TV, qualified interpreter, reader, communication device or other communication assistance; and

(iii) Based on the provision of the reasonable accommodation outlined in paragraph (G)((3)(a)(ii) of this rule, advise the person served of his/her right to request the presence of the client rights advocate during the interview.

(b) Notifying the following persons and agencies:

(i) The deputy director of hospital services of ODMH;

(ii) The Ohio state highway patrol immediately, and sheriff, or police if applicable when there are allegations of criminal acts;

(iii) With appropriate authorizations for release of information, the patient's family, next of kin, or guardian(s) of the person as soon as possible but no later than twenty-four hours and, when completed, ofthe results ofthe investigation; and

(iv) The RPH client rights specialist.

(c) Immediately removing an employee alleged to be involved in suspected patient abuse or neglect from direct patient care until completion of the investigation when the incident dictates such action.

(4) Each CEO or designee shall promulgate procedures for reporting, investigating, and resolving incidents of alleged abuse and neglect for community support network employees.

(5) The CEO or designee shall be responsible for implementing prompt employee disciplinary action pursuant to departmental policy and under section 124.34 of the Revised Code when a charge of patient abuse or neglect by an employee is substantiated.

(H) Employee responsibility

(1) Each employee who has knowledge of apparent or alleged abuse or neglect of a person served shall be obligated to report such incidents to his or her immediate supervisor, or designee, who will immediately inform the CEO and the security/police department. Any injury to a person served shall be reported immediately to a physician.

(2) The employee shall follow through by completing the appropriate ODMH designated incident form. Failure to do so shall be considered neglect of duty and the employee will be subject to disciplinary action.

Effective: 08/25/2011
Promulgated Under: 111.15
Statutory Authority: 5119.01
Rule Amplifies: 5119.01 , 5119.02 , 5119.27 through 5122.301
Prior Effective Dates: 12-24-1979, 7-1-1980, 11-22-1981, 2-1-2000, 7-15-2002