TITLE
Disruptive Patient Behavior
FACILITY
PAGE
Winchester Medical Center
DEPARTMENT
All Departments
1 of 4
FUNCTION
Patient Safety
EFFECTIVE
September 1, 2012
RESOURCE
Risk Management
Corporate Compliance
Security
REVIEWED/
REVISED
September 1, 2012
LOCATION
Risk Management
APPROVAL
SIGNATURE
______________________President WMC
______________________
SIGNATURE
TITLE
TITLE
______________________Director of Security
______________________Director of Risk
Management
Purpose: To provide guidance to WMC staff for handling mentally competent patients or
patient visitors who engage in disruptive behavior on the hospital premises.
Policy: WMC is committed to providing a safe, therapeutic environment for patients and their
visitors. This policy sets forth guidelines for handling mentally competent patients, or patient
visitors, who engage in disruptive behavior that may adversely impact patient, visitor and staff
safety.
Definitions: “Disruptive behavior” is any inappropriate behavior by a mentally competent
patient or his/her visitors that may be disruptive to the patient’s own care; the care of other
patients; the safety of patients, visitors and hospital staff; or the general operation of the hospital.
These situations can include the following:
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Refusal of patients to comply with reasonable requests from medical or nursing staff
member. This includes refusal to comply with medical protocols or hospital rules, such as
smoking on hospital premises.
The possession or the use of illegal drugs/substances on hospital premises.
The use of alcohol and other medications or substances that are not prescribed by the
treating physicians.
Disruptive confrontations, either physical or verbal, with patients, visitors or staff.
Verbal threats and/or acts of physical assault.
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Procedure:
1. Documentation:
a. When inappropriate behavior first occurs, the nursing staff and/or physician should
counsel the patient with the intention of verbally de-escalating the disruptive behavior.
Patient care staff are to document the disruptive behavior (including the date and time),
as well as record that the patient was informed that such behavior is inappropriate and
must cease.
b. Instances of inappropriate or persistent non-compliant conduct should be documented to
establish a pattern of repetitive disruptive behavior or non-compliance or otherwise
inappropriate conduct.
c. All efforts to establish and maintain a satisfactory hospital/patient or hospital/patient
relationship should be documented. See #2 below for further guidance.
d. Incidents of patient disruptive behavior that are not resolved at the bedside must be
submitted to Risk Management through the RiskQual Reporting System.
2. Achieving Compliance: Efforts should be made to achieve compliance from the patient in
order to protect the safety to all hospital patients, and staff. As mentioned above, these
efforts to de-escalate should be documented in the medical record.
a. A Team Huddle may be organized and conducted to develop a Risk Management Patient
Safety Plan. The team may include, but is not limited to, the Primary Nurse, Charge
Nurse, Security, Medical Provider, Social Work, Case Management or Risk
Management.
b. Inpatients may be provided with the Patient’s Responsibilities and Code of Conduct.
Notices of patients’ responsibilities will be posted for outpatients and emergency
department patients.
c. Counseling may be provided to the patient, his/her family or others involved in the
patient’s care. At least two (2) members from the team should meet with the patient.
Counseling should focus on the patient’s responsibilities, the Safety Plan for the patient,
the need for compliance and the consequences of continued inappropriate behavior.
d. Additional guidance on handling situations described in this policy may be found in the
Disruptive Patient Behavior Protocol available at the Risk Management site on the Valley
Health Intranet.
3. Verbal/Physical Threats: In the event that the patient makes verbal or physical threats of
any nature to other patients, staff, equipment or hospital premises:
a. Staff should contact hospital security immediately. Staff report is to include the patient’s
name, location, specific examples of disruptive behavior, and the number and type of
attempts to de-escalate this behavior before calling for Security assistance.
b. The charge nurse, clinical manager and/or Director/nursing supervisor need to be
notified. If it is night shift, the administrator on-call or nursing supervisor needs to be
notified.
c. A RiskQual report must be submitted as soon as possible.
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d. If the aggressive behavior does not stop, Security may notify local law enforcement to
report and request their assistance, as deemed appropriate.
4. Violations of No Smoking Policy: Efforts should be made to achieve compliance from the
patient as set forth above. In addition, the attending physician may discuss the potential of
use of nicotine substitutes during the patient’s admission.
5. Alcohol/Drug Use: If it is witnessed or suspected that the patient may be using alcohol,
illegal drugs or medications not approved by the hospital pharmacy:
a. Staff should contact hospital security immediately.
b. The charge nurse, clinical manager and/or Director/nursing supervisor need to be
notified. If it is night shift, the administrator on-call or nursing supervisor needs to be
notified.
c. A RiskQual report must be submitted as soon as possible.
d. Room search needs to be performed and completed by Security.
e. Any medications found during the room search are to be sent to pharmacy.
f. Any illegal drugs or drug paraphernalia need to be confiscated and removed. It will be
up to Security to decide whether to notify the local Police Department.
g. Patients suspected of using alcohol or illegal drugs should not be allowed to leave their
room for their safety as well as the safety of others. Patients should be counseled that by
leaving the room it is considered against medical advice.
h. If the behavior does not stop, Security may notify local law enforcement to report and
request their assistance, as deemed appropriate.
6. Removal of Personal Property: In certain circumstances, the hospital may remove from a
patient’s room personal property that is disruptive to the patient’s care, increases risk to the
patient’s safety, impacts other patients or poses risk to the hospitals equipment or premises.
For example, the patient may use a laptop to watch pornography or other content that is
considered objectionable to other hospital patients, visitors or hospital staff.
a. Security, with guidance from Risk Management, must be involved in the decision to
remove property.
b. There must be documentation in the medical record that the patient has been advised that
his/her use of the personal property is disruptive. If property is temporarily removed from
the patient’s possession, the date time and property description is to be documented in the
medical record.
c. Any removed property must be stored in the Security Department. At the time of removal
of a patient’s personal property, Security department staff will advise the patient that their
property will be secured and protected in a secure location.
d. All removed personal property will be returned to the patient at discharge.
7. Denying A Patient Visitors: A patient has a right to receive visitors, but this right may be
limited or restricted when visitation would interfere with the patient’s own care, the care of
other patients, or the safety of patients, visitors or hospital staff.
a. If a patient is denied visitors, staff should document the reasons why the visitation would
interfere with care of the patient or other patient, or with the safety of patients, staff and
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others. The patient care staff will also document the date, time and summary of the
patient / family conversation that demonstrates that the patient was advised of limited
visitation.
b. The hospital may exclude a visitor if the visitor engages in disruptive, threatening or
violent behavior of any kind.
c. The hospital may exclude a visitor if the visitor is providing, or there is reasonable
suspicion that he/she is providing, a patient with alcohol or illegal drugs.
8. Administrative Discharges: The patient’s repeated unacceptable behavior may be
considered evidence the patient’s intent to terminate the hospital/patient relationship. In
these circumstances, the hospital may consider an administrative discharge if a patient
refuses to cooperate or exhibits continued unacceptable behavior, and the patient’s medical
condition permits.
a. Risk Management must be involved in the decision to administratively discharge a
patient.
b. A RiskQual report must be submitted.
c. Administrative discharge may be pursued only if there is documentation of the patient’s
disruptive behavior and the attempts of hospital staff to counsel the patient about his/her
behavior.
d. The attending or treating physician must determine and document that based on their
clinical judgment, the patient’s medical condition is such that discharge is not likely to
result in serious physical harm to the patient.
• The attending physician must conduct a thorough physical assessment of the patient
and document the patient’s physical and mental condition prior to discharge.
• The attending physician must explain to the patient that the patient’s repeated
behavior evidences the patient’s intent to terminate the hospital/patient relationship.
The physician must explain the patient’s current medical condition, the type of care
which should be sought by the patient, and the timeframe within which such care
should be obtained.
• Although the current hospital/patient relationship may be terminated, the patient must
be advised that he/she will not be denied emergency medical care in the future.
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