1. 1. Police Contact
1.1. When the police are called or they come in contact with an individual experience a mental health crisis, they make the decision to warn, arrest or charge the individual.
1.1.1. Supports: family and community
1.1.2. Emergency department division; treatment and crisis support services
2. 2. Arrest/Charge by Police
2.1. Police will decide whether to charge or arrest an individual based on the seirousness of the crime(s), public safety concerns and the criminal code.
3. 3. Bail Hearing
3.1. At the bail hearing, the court may decide to release the individual until their first court appearance. They may also remain in custody at a detention centre or released with conditions requiring the individual to report to a bail program
4. 4.Court Appearance
4.1. Fitness, NCR or Treatment Order
4.1.1. Form 48: Assessment Order- it signed by a judge and allows for the assessment of the individuals fitness to stand trial or criminal responsibility. Treatment Order- purpose is to restore an unfit accused's fitness to stand trial as fast as possible, allowing for the trial to proceed in a timely fashion.
4.1.1.1. Admission to Forensic Assessment Unit
4.1.1.1.1. Mountain 3 Admission Checklist
4.1.1.2. These orders cannot last longer than 30 days. Once they return to court, a ruling will be made and ORB dispositions will be listed.
4.1.1.2.1. Mountain 3 Return to Court Package
5. 5.Trial
5.1. Unfit, NCR ruling
5.2. Ontario Review Board: this panel will review each case and determine the next step in privilege level.
5.2.1. Absolute Discharge
5.2.1.1. Patients are released on their own recognizance
5.2.2. Condtional Discharge
5.2.2.1. He or she is under the jurisdiction of the ORB and must follow conditions as outlined by ORB and will be reviewed annually until they are given absolute discharge
5.2.3. Detention Order
5.2.3.1. He or she is put on a Warrant of Committal/Form 49 and will be give a disposition that detains the accused in hospital. Privilege levels and conditions are specifically listed
6. Systems Issues: Patient Violence Against Nurses
6.1. Nurses are often told that this is "part of the job"
6.2. Management fails to adequately staff units and provide support for short-staffed units
6.2.1. Increases the risk of injury = costs associated with injury account for approx. 30% of the overall costs of ill-health and accidents
6.3. The lack of care from management leads to nurses quitting and therefore increases the shortage of nurses
7. 6. Sentencing
7.1. When an individual is sentenced for an offence, there are several possible sentencing options available to the court including being released on probation (i.e. conditional discharge), paying a fine, or remaining in custody.
8. 7. Reintegration
8.1. After completing the sentence, the individual begins the process of reintegration into the community obtain employment or attend programs suitable for addressing their needs. Reintegration planning often begins while the person is serving the sentence.
9. 8. Probation/Parole
9.1. Community supervision is required for individuals who have served a period of time in custody. A probation/parole officer
10. Who's Involved?
10.1. Police officers
10.2. Judge or Crown
10.3. Probation officers
10.4. Healthcare team
10.4.1. RN, RPN
10.4.2. OT, RT, SW
10.4.3. Physicians, psychologists, psychiatrists
10.5. Community resources and workshops
10.5.1. Public health nurses
10.6. Ontario Review Board
10.6.1. psychiatrist
10.6.2. mental health professional i.e. psychologist
10.6.3. a person from the community with a mental health background
10.6.4. chairperson (i.e. lawyer, retired judge)
11. Unit Protocols
11.1. Seclusion
11.1.1. Initial Assessment: includes a biopsychosocial assessment of the individuals who are at risk of requiring seclusion, and individuals for whom seclusion is contraindicated for whom be used with extreme caution
11.1.2. Initiation: (1) seclusion may be initiated by the attending/duty physician or, in his/her absence by the nurse/unit manager or nurse in-charge (2) when seclusion is initiated by a nurse/unit manager or nurse-in-charge, the seclusion will be obtained immediately, (3) physician assessment following seclusion of a voluntary patient will be considered a clinical and legal priority and an in-person assessment by the physician will occur immediately, (4) upon initiation of seclusion the nurse and attending/duty physician will consult regarding: pt mental and physical status and any risks associated with the initiation, events leading up to seclusion, interventions to end seclusion
11.1.3. Seclusion Reassessment and Reorders: (1) the attending/duty physician will conduct an in-person assessment of the patient within 8h of the initiation of seclusion and at subsequent intervals not to exceed 24 hours, (2) the ongoing need for seclusion will be assessed continuously q4 hours, (3) prior to the next formal review period, the nurse-in-charge determine a need for consultation regarding the patient's mental or physical status, (4) if seclusion is terminated prior to an in person assessment by the attending/duty physician, the physician must personally assess the patient within 24 hours of the initiation of seclusion
11.1.4. Monitoring Requirements: (1) the individual in seclusion will be directly and continuously observed (1:1) for the first hour of seclusion, (2) after the first hour of seclusion, the level of observation may be reduced, unless the patient's condition warrant ongoing continuous (1:1) observation, (3) at no time will an individual in seclusion be directly observed at less than every 15 minute intervals, (4) vital signs will be monitored and recored at least once every 4 hours, unless ordered more frequent or patient history/clinical findings suggest that more frequent assessment is indicated, (5) monitoring must include close attention to the safety of the physical environment, any sign of physical or emotional distress, as well as monitoring of mental status and anticipation of hydration/nutritional and elimination needs
11.2. Discharge
11.2.1. Discharge Checklist: (1) doctors order for discharged is received prior to discharge, (2) "green sheet" is accurately completed, (3) complete institutional transfer sheet if patient is being transferred to a correctional facility or another psychiatric facility, (4) ensure the patient's belongings are packed and prepared, (5) document full mental status in the nursing notes section at time of discharge (6) complete discharge navigator in Dovetale, (7) obtain patient ID badge and return it to security, (8) complete ORB report for patient as required, (9) notify ORB clinic of upcoming appointments/meetings, (10) have discharge script, after visit summary completed, prior to discharge
11.3. Physical/Chemical Restraints
11.3.1. Initiation of Physical Restraint
11.3.1.1. (1) in the absence of immediate access to a physician when a physical restraint is indicated, the nurse/unit manager or nurse in-charge may authorize the application of restraint (2) when a non-physician authorizes the application of a restraint, the attending/duty physician will be noted and a written or verbal order will be obtained immediately, (3) upon initiation assessment of patients current physical and mental status and any risks associated, discussion of events leading up to the event, less restrictive measures initiated, (4) the nurse/unit manager and operational services manager will be notified of the initiation of initial restraint; nurse supervisor will be notified of the initation.
11.3.2. Initation of a Chemical Restraint
11.3.2.1. (1) a medication order that specifies "for restraint" will only be read as a chemical restraint oder. an order that does not specify "for restraint" will be read as a treatment order, and must therefore be proceeded by valid consent, (2) medication restraint orders will specify the medication, its intended used as a restraint, dose, route and frequency, (3) in the presence of a time-limited order authorizing the administration over a 24h period, the nurse in charge may then decide if and when the chemical restraint should be administered within that period (4) least restraint principles must be applied; administered via the least intrusive route possible i.e. oral prior to IM