Center for Change Policies and Procedures
Caution Status
POLICY SECTION: PATIENT SAFETY
EFFECTIVE DATE: 01/17/2005
LAST REVIEW/REVISION DATE: 2/2016
REFERENCE:
Policy
Caution Status is a specific level of care. It is implemented with the intention of
keeping each patient safe, keeping the program operating smoothly, and in the
best benefit of all patients in the program. It will focus help, support and
intervention for those who are struggling in the program and in need of extra
supervision. It will help patients make choices that are not self-defeating or
destructive. It will help patients to find positive coping skills.
Procedure
1. Patients of CFC are required to abide by the Center’s code of conduct,
safety code and program policies. In abiding by those codes and policies,
they will not engage in the behaviors or patterns of behavior which break
the conduct or safety codes. Behaviors of concern include those listed
below:
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Physical violence / Verbally abusive behaviors
Any real or implied threat of violence
Threat or actual behavior to hurt self via self-mutilation, suicidal behaviors,
or any other dangerous behavior
Destruction or vandalism to any property (if it poses a safety risk to self or
others)
Theft (if it poses a safety risk to self or others)
‘Cheeking’ and/or stockpiling medications
Bringing drugs, alcohol, undisclosed and unapproved medications, or any
potentially harmful contraband
Use of illegal drugs or alcohol, or misuse of prescription drugs while in
Center for Change or while out on pass
Possession of, transmitting, or aiding and abetting the possession or use
of any contraband which can by physically or emotionally damaging
(weapons, drugs, alcohol, pornography, sharps, undisclosed and/or
unapproved medications, stolen items, etc.)
AWOL participation: planning an AWOL, running or helping, hiding or
failure to report another resident’s plan
Sexual acting out or misconduct
Continuous purging behavior or food refusal that presents as a medical
risk
2. Decision for Caution Status placement will be made by 3 or more clinical
and/or direct care staff including one of the Clinical Directors or Director of
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Clinical Services. There is not a maximum time limit for Caution Status;
however, Caution Status will be reviewed by the treatment team weekly.
3. Caution Status patients are automatically placed on the Awareness Phase
(1) and line of sight (LOS).
4. Pt. will be educated about guidelines by the nurse or Caution Status tech:
 If patients are placed on caution status for suicidal ideation or active self
harm, the patient will need to wear hospital scrubs. Patients that are
placed on caution status for reasons not related to self harm or suicidal
ideation will not be required to wear scrubs and this will be included in the
therapist order. Patients are allowed to wear a long sleeve shirt under their
scrubs with a therapist order.
 Patient will not be allowed to wear make-up.
 Patient will not be permitted to attend any off campus or outside
activities.
 Patients are not allowed have any personal belongings unless there is a
written order.
5. Patients will be given specific written assignments to complete while on
Caution Status and will not be permitted free time with other residents.
Assignments must be reviewed by the therapist and treatment team
before coming off of Caution Status.
6. Caution Status patients will be combined (RTC and Inpatient) and follow
the inpatient schedule if an inpatient is placed on Caution Status.
7. If a patient requires specific medical supervision, as ordered and approved
by the medical team, the patient may combine with the caution status
patients and participate as deemed appropriate for their condition. In
some cases, Medical 1:1 supervision is required, which would exclude
them from combining with the caution status patients and that patient
would follow programming with their own staff member under medical
supervision 1:1.
Procedures and Guidelines while on Caution Status
1. Patient is informed of Caution Status beginning by therapist or clinical
team. Patient is given printed Caution Status material and will change into
scrubs, if applicable.
2. Patient may not watch TV; listen to music or personal ipod unless a
specific order is written to the contrary.
3. Patient is on 100% dietary plan. Patient will eat meal and snacks at the
scheduled time but at a table separate from the group. If an AWOL risk,
the patient will eat in the family room with a Caution Status tech.
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4. Patients on Caution Status will sleep in the caution status room (this room
has camera surveillance).
5. Patient is not to be in common living areas. Patient will be with the group
only during approved groups and classes for Caution Status.
6. Patient may not have contact with other residents. No talking (verbal and
non-verbal), no passing notes.
7. The patient will be given a Caution Status unit bin to use while on Caution
Status. This will contain the material needed to complete assignments.
Any items given to the patient must be searched by a staff member before
given to the patient. Patient will not be allowed to have personal items
unless written order.
8. No free time is to be spent with other patients. While on Caution Status,
time is to be spent completing the following therapeutic assignments: (if a
patient is placed on CS more than once, there will be additional
assignments)
9. If self-mutilation or bodily self-harm is the behavior in focus, the patient will
receive daily gown searches given by the nurse while on CS. Informed
consent for adolescents must be obtained and patient rights reviewed for
adults.
10. The primary therapist will set goals for the patients and become actively
involved in the Caution Status program. These are the assignments:
 In writing, acknowledge the inappropriate behavior(s) which
implemented Caution Status.
 In writing, explain the patients responsibility in that behavior.
 Write the cycle of addiction and how this episode is a part of that
addictive pattern of behavior.
 Write about the natural and programmatic consequences of that
behavior (within Center for Change and in the world outside of Center for
Change).
 In writing, explain the need that is attempting to be met from this
behavior.
 Write five “better ways” to get that need met.
 Write an action plan to get needs met in a healthy way and avoid
Caution Status in the future.
 The primary therapist will give additional assignments per need
throughout Caution Status.
 The supervising direct care staff may add assignments and help the
patient find relevant reading material from the Center for Change library.
 With a written therapist order and in the presence of direct care staff,
patient may call family to report behavioral problems and seek feedback
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and support. Patient may not make or accept any phone calls without a
written doctor’s order.
 Patient will make acknowledgment, apology, and restitution if applicable
to those affected negatively by their behavior(s).
 Express your anger/ frustration on paper using colors and images rather
than words. Use as many pages as you need with a minimum of 5 pages.
Give these pictures to your individual therapist in your next session to use
in session. You may find it helpful to dispose of some of the artwork
together once you have processed. To be done in the visual journal with
oil pastels.
 Write a 2 page letter of hope with your non-dominate hand using the oil
pastels. Allow your inner child to speak to your intuitive and emotional
self. To be done in the visual journal with oil pastels.
 Draw a peaceful place and go there in your mind. As you draw your
peaceful place, imagine the smell, touch, taste, and sounds of the calming
surroundings. To be done in the visual journal with oil pastels.
11. Patient is to complete the following assignments (in addition to above
assignments) if it is her second time on Caution Status:
 Look into the future 5-10 years and write a letter to yourself addressing
the following things:
o Tell yourself the things you would do differently and what you like
about where you are now.
o What has it taken to get where you are now?
o How have you done in your commitment and ability to take
ownership of your life?
o What do you wish you had learned when you were on Caution
Status that would have helped you now?
 Set up your own guidelines and consequences for your behaviors.
 Work on step 4 in your 12-step workbook and pick two additional steps
to work on.
 Read a book on forgiveness and outline method to self-forgiveness.
Share with peers and family as directed by your therapist. Book: Forgive
for Good by Fred Luskins
 Write a letter of apology and amends to yourself. Outline a plan of selfnurturing and self-care.
 Review your Life Quest book or other assignments as given by your
therapist. Establish goals based on these to prevent destructive
behaviors. Complete unfinished assignments from Life Quest.
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12. Written assignments will be accepted by the primary therapist. Patients
may be asked to redo assignments if they lack substance, thought and
consideration or if they need to be longer.
13. Only after written therapeutic assignments are completed can the patient
free draw (except for art assignments), free write, or read assigned
material from the Center for Change library. There is no napping time
while on Caution Status. If more assignments are needed the Caution
Status techs or primary therapist can provide more assignments.
14. Patient will attend and participate in the following groups/activities: (no art
room)
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Academic Classes
Body Image Group
Open Group
Dietary Class
Experiential Rec Therapy Group
12-Step Group
Music Therapy
Spirituality Group
Self-Esteem Class
Life-Skills Class
Drug and Alcohol
Ceremonial
Honesty
Goal Setting
15. Patient will not attend the following groups/activities:
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Community Meeting
Free Time
Art Class or Art Therapy
Cooking Class
Exercise (Nia, Yoga, Weights, PE)
Leisure Rec. Therapy Activities
Off Campus Activities/Education Field Trips
Friday Night Snack/Movie
Study Hall
Sunday Togetherness Devotional
16. Therapists are not allowed to write special orders or make
exceptions for patients while on Caution Status. Patients and
therapists are to follow Caution Status rules and guidelines.
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Guidelines for Caution Status : “Line-of-Sight”
Caution Status “line of sight” will be implemented for patients who present with a
significant level of depression and suicidal preoccupation, or have actively selfharmed. Patient will be placed on “Caution Status” and these procedures will be
implemented, along with the following:
1. A therapist or physician will conduct a face-to-face evaluation of patients
placed on line-of-sight within 24 hours of the time precautions were
implemented.
2. Patient will reside in a designated area to provide close observation during
waking and sleeping hours. Movement from the designated area will
require staff escort.
3. The patient will sleep in the caution status room and staff will be stay in
that room with the patient to observe the patient. This bedroom is
equipped with camera surveillance.
4. The patient can eat in the kitchen with staff without sharp utensils. Count
flatware before and after use.
5. Patient will need to wear hospital scrubs if on caution for self harm or
suicidal ideation since certain types of clothing such as zippers, buttons,
belts, drawstring pants, shoes with laces, etc. may present a potential
danger or patient has harmful items hidden in their clothing.
6. The person assigned to the patient will document every 15 minutes on the
Caution q-15 minute check form and will also document for shift report and
complete all charting.A licensed nurse will assess the patient and
document in the Progress Notes each shift.
7. The patient will be allowed to participate in unit treatment activities as
appropriate.
8. Pass privileges are not granted until the caution status precautions are
discontinued. The patient is not permitted to attend off-unit activities until
the precaution is discontinued.
9. The patient and room are checked once per shift for hazardous items by
therapist or physician order.
10. Therapist or the on-call therapist is responsible to meet with the patient
daily while the patient is on cautions status, with the exception of Sunday.
11. Patient will be given a caution bin that contains all approved items and
which does not contain contraband.
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Guidelines for. Caution Status: “One-on-One”
Caution Status “one-on-one” will be implemented for patients assessed to be at
immediate high-risk for committing suicide or harming one’s self. Patient must be
within five feet of staff members and line of sight in the bathroom, shower and
while sleeping. Patient will be placed on “Caution Status” and all of the standard
caution procedures will be implemented along with the following:
1. When one-on-one caution status is implemented, the physician or
therapist will complete face-to-face evaluation of the patient daily. This
evaluation will be documented in the progress note.
2. The patient will be assigned a one-to-one staff member who will remain
within arm’s length of the patient and maintain constant visual contact with
the patient at all times. Remember, keep patient within sight and within
reach at all times. The Clinical Director will determine if the patient can be
with other patients on caution status or if the patient needs to be
separated from the other caution status patients.
3. During waking and sleeping hours, the patient will reside in a designated
area. Patient may need to be on elopement precautions.
4. The patient will need to eat on the unit and without sharp utensils. Count
flatware before and after use. Staff will notify kitchen that patient needs to
eat finger foods.
5. The staff member must be in the same room with the patient at all times.
A staff member of the same sex should accompany the patient into the
bathroom. The staff member remains outside the bathroom door (leaving
the door ajar) during hygiene and toileting activities to allow for privacy but
the patient will need to be line of sight the entire time.
6. While the patient is in bed, it is appropriate to request that the patient keep
her hands on top of the covers to prevent self injury under the covers.
7. Patient will be allowed to participate in some unit activities as appropriate,
and these need be directed by the therapist. Therapist will be responsible
to outline daily schedule for the patient.
8. Therapist or the on-call therapist is responsible to meet with the patient
daily and assess safety and document this in the chart. On- call therapist
will be responsible to call the unit on Sunday and discuss patient’s status
with the nurse on duty.
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9. One-on-one record: The patient’s location and activity will be noted every
fifteen (15) minutes. A summary note will be made every hour. This might
include patient activity, mental status, level of cooperation, pertinent
conversations, and patient reports. The caution tech will send out an email report to all direct care staff, therapists and dietitians every four hours
updating staff on the patient’s progress and behaviors.
10. If the patient needs one-on-one observation for longer than 24 hours, and
if suicidal risk is deemed significant, the patient will be transferred to Utah
Valley Regional Medical Center or a similar appropriate acute psychiatric
hospital at the close of the 24 hours for evaluation and possible admission
to the Acute Inpatient Unit for safety and further evaluation of mental
status.
Guidelines for Caution Status: AWOL precautions
Caution Status “AWOL precautions” will be implemented for patients assessed to
be at immediate high-risk for attempting to elope from the facility. Patient will be
placed on “Caution Status” and all of the standard caution procedures will be
implemented along with the following:
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Not allowed to wear shoes or jackets. Must wear slippers.
LOS and must be within arm’s length of staff member at all times.
All meals and snacks are brought to the patient, the patient is not
allowed to walk to the dining hall.
During the day, the patient is to stay in the inpatient basement. If
there is high safety risk, the patient will be in the family room across
the from the nurse’s station. The Director of Clinical Services or
Clinical Director will write a clinical order for this.
Sleep in the caution room with a staff member present in the room
at all times.
If the patient is a RTC patient, medications are brought to the
patient.
Guidelines for Caution Status: Q-15 Minute
“Q15-minute” Caution Status will be implemented for patients stepping down
from LOS, One-on-One or AWOL status caution. Patients on q-15 minute check
caution are no longer reporting thoughts of self harm or no longer making
attempts to elope from the facility.
1. A therapist or physician will conduct a face-to-face evaluation of patients
to determine the patient is appropriate to step down to q-15 minute
Caution Status.
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2. Patient will reside in a designated area to provide close observation during
waking hours. Movement from the designated area will require staff
escort.
3. The patient will sleep in the caution status room but staff will not need to
be present in the room. This bedroom is equipped with camera
surveillance.
4. The patient can eat in the kitchen with staff with normal utensils. Count
flatware before and after use.
5. Patient will need to wear hospital scrubs if on caution for self harm or
suicidal ideation since certain types of clothing such as zippers, buttons,
belts, drawstring pants, shoes with laces, etc. may present a potential
danger or patient has harmful items hidden in their clothing.
6. The person assigned to the patient will document every 15 minutes on the
“Q-15 minute check form.” A licensed nurse will assess the patient and
document in the Progress Notes each shift.
7. The patient will be allowed to participate in unit treatment activities as
appropriate.
8. Pass privileges are not granted until the caution status precautions are
discontinued. The patient is not permitted to attend off-unit activities until
the precaution is discontinued.
9. The patient and room are checked once per shift for hazardous items by
therapist or physician order.
10. Therapist or the on-call therapist is responsible to meet with the patient
daily while the patient is on cautions status, with the exception of Sunday.
11. Patient will be given a caution bin that contains all approved items and
which does not contain contraband.
Guidelines for Medical One-on-One
Medical One-on-One is ordered by the psychiatrist, the NP or anyone acting on
their behalf. Medical One-on-One requires one staff member to be with with one
patient at all times, unless the order specifies the patient can be combined with
caution status patients. Specific medical markers will be discussed with the unit
RN as well as the staff member performing One-on-One observations to ensure
the medical safety of the patient. Patients on medical One-on-One may
participate in regular programming as long as the group or activity is not
contraindicated in their medical care or stability and their One-on-One staff
member is present and available to monitor.
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Failure to Respond
If a patient fails to complete assignments, comply with the Caution Status rules
and guidelines or otherwise positively respond to Caution Status within 7 days,
then the patient will be placed on placement review status in the treatment team.
Discontinuing Caution Status: The Process
Patients will be stepped off down from Caution Status when the following
requirements have been met:
1. Written assignments were completed and accepted by therapist and the
treatment team.
2. Patient made appropriate acknowledgment, apology, and restitution to
those affected by their behavior(s).
3. Patient deemed safe enough to be off Caution Status.
4. Patient displayed appropriate behavior(s) while on Caution Status and
received written feedback from Caution Status techs suggesting patient’s
behavior in areas of focus were acceptable or exceptional.
5. After Caution Status is discontinued, patient will remain on Q-15’s.
6. After Caution Status is discontinued, patient will remain on the Awareness
Phase (1) until re-application and acceptance to a higher phase occurs.
Re-application to a higher phase requires a request letter written to
treatment team. Treatment team will decide which phase is appropriate
for the patient to advance to.
Procedures for Caution Status Tech:
1. Supervise up to three caution status patients at a time. Unless the patient
is one to one.
2. Wear a buzzer anytime when assigned to be with a patient on caution
status.
3. Chart every hour on the patient in bluestep.
4. Complete check sheet every 15 minutes.
5. Send an e-mail out to direct care staff, therapists, and dietitians every four
hours summarizing the patient’s behaviors.
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6. Caution shift report from each tech supervising caution status patient.
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