1. At Risk Patients

2. Who is “At Risk” It is YOUR assessment as the nurse caring for the patient that determines if the patient is at risk. A patient will be determined to be “At Risk” if they were to wander or go missing and would be at risk for harm to themselves or others if not found and returned to a safe environment. The following criteria can also cause a patient to be determined to be “At Risk.” The patient is (any of the below criteria): Legally committed Has a court-appointed legal guardian Is considered dangerous to self or others, due to being; – On 96 hour hold awaiting transfer to a psychiatric facility – Awaiting psychiatric evaluation for competence – Incapacitated, mentally or physically – Incapable of making sound decisions

3. What is an “At Risk Patient” Policy PC-54 Who are they: - incapacitated -incompetent -handicapped -incapable of sound decision -Resident of nursing home -Resident of mental health facility -Resident of correctional facility They must also: -deemed a danger to self or others -currently on 96 hour detention -being considered for 96 hour detention -have the potential to wander - C.A.M. score > 3

4. Purpose The Missing “At Risk” Patient/Person Emergency Response Plan establishes a plan for response when an adult patient or visitor who is identified as being at risk of harm to self or others has gone missing from their expected location. This plan does not apply to children. Call Emergency Response Number and Announce CODE GOLD

5. Mitigation - All patients are assessed for the “At Risk Patient” criteria upon admission to the health care facility. -“At Risk Patients” are promptly identified by their initial physician/nursing assessment. -Measures are put into place to decrease the likelihood that they will become missing and increase the likelihood of finding them should they become missing such as placing them in a special colored gown, removal of their personal clothing from their room, and routine rounding to ensure they are accounted for. -Staff are trained on the appearance of the special colored gown to be “on the lookout” for the “At Risk Patient”.

6. Special colored gown “At Risk Patient” Gown with suicide risk “Non-At Risk” Patient Gown Patients who are; on 96 hour detention orders, and those patients presenting with a mental health issue involving suicidal/homicidal ideation, self-injurious behavior or significant psychosis who are violent or unwilling to be assessed will remain attired in the red disposable pajamas for their safety. Patients who are identified by the CAM to score > 3, who have the potential to wander will be placed in a red cloth non-disposable hospital gown. “At Risk Patient” Gown without suicide risk

7. Please contact the security department if you have a patient that qualifies as “At Risk” An officer will present with a form, printed on yellow paper. This form will – Aid the Clinical Staff, Sitters, and Security in understanding why the patient is “At Risk” – Aid in locating the “At Risk” patient in the event of elopement. Security will round on each unit to assure that a current list of “At Risk” patients is maintained at Security Dispatch