Children's Hospital and Regional Medical Center (Clinical Policy/Procedure: M ) Medical Hold: Temporary Protective Detention or Custody

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1 Children's Hospital and Regional Medical Center (Clinical Policy/Procedure: M ) Medical Hold: Temporary Protective Detention or Custody POLICY: The Attending Physician, SCAN (suspected child abuse or neglect) Medical Consultant or the Administrator On-Call (AOC) may place a hold on a child only when reasonable cause exists to believe that there is imminent danger to a child s safety if left in the care and custody of a parent or guardian. (RCW ) Once Child Protective Services (CPS) has been notified, and while a medical hold is active, decisions regarding continuation of the medical hold and placement of the child become the responsibility of CPS, law enforcement or the court. PURPOSE: A medical hold allows Children s to temporarily detain a child when there is reasonable cause to believe that permitting a child to be released to or to continue in the care of the parent, guardian, custodian, or person legally responsible for the child s care presents an imminent danger to the child s safety. A medical hold is normally utilized when other efforts to prevent the parent(s)/caregiver(s) from removing their child against medical advice have been attempted. In certain circumstances, however, the best interests of the child may dictate immediate imposition of a hold. PROCEDURE: I. Decision to Place a Medical Hold (also known as Protective Detention or Custody): A. A Medical Hold May Be Placed: 1. When there is reasonable cause to believe that permitting a child to be released to or remain in the care and custody of the parent, guardian, custodian, or person legally responsible for the child's care presents an imminent danger to the child's safety. 2. Whether or not medical treatment is required for the child. 3. Only for a child who is physically present at Children s. B. A hold requires immediate notification to Child Protective Services (CPS) and/or law enforcement that reasonable cause exists to suspect child abuse or neglect. 1. Notification will be made as soon as possible, because the sole purpose of a hold is to protect the child for a period not to exceed 72 hours while CPS evaluates whether to seek temporary custody. 2. The hold automatically expires after 72 hours unless CPS has sought and obtained temporary custody orders or makes a written determination that the child's safety will not be endangered if the child is returned to the caregiver's/parent s care and custody. C. A medical hold is not appropriate for cases that are already active with CPS unless new issues or information warrant a new CPS referral.

2 Page 2: Clinical Policy/Procedure: Medical Hold: Temporary Protective Detention or Custody II. Individuals Responsible for Activating the Medical Hold: A. At Children s, the Attending Physician, the Administrator On-Call (AOC), the Nursing Supervisor and the SCAN Medical Consultant, if involved, will communicate and jointly make the decision regarding the use of a medical hold. 1. This procedure implements the provisions of Washington law, which provides that an administrator of a Medical Center or any licensed physician with active medical staff and admitting privileges may make the decision to detain a child. (RCW (1)(2)). 2. At Children s, the term Administrator means the administrator on call, or AOC. At Children's, the decision to place a hold must include all the individuals identified in this paragraph, to assure good decision-making on behalf of and in protection of the children we serve. B. Once the decision is made, the Administrator On-Call or Attending Physician or his/her designee will as soon as possible, but in no case longer than 72 hours after placing the medical hold, notify the appropriate law enforcement agency or Child Protective Services (CPS). C. It is preferred, however, that both law enforcement and CPS be called and advised of the situation in the event that immediate further involvement is required of either agency. D. The Attending Physician, AOC or his/her designee must notify Security through the hospital switchboard as soon as the decision to institute a hold has been made: 1. Security will immediately implement a CASPER to institute a patient watch with direct Security presence on the floor or in the room, as determined in consultation with the Nursing Supervisor and Charge Nurse. 2. Whenever the family leaves the room, Security will check for presence of the child. (See Clinical P&P, Clinical Action Safety Plans Evaluating Risk (CASPERs)). 3. Termination of the patient watch while the hold is in effect requires concurrence of the Director of Security or his designate, the patient s Attending Physician, Social Worker and Nursing Supervisor and the Children s Protection Program (CPP). a. If the patient watch is withdrawn, notify the AOC, Medical Director and Nurse Executive. 4. Within twelve hours of initiating a hold, an interdisciplinary team meeting must be held (See Section IV B.). E. At the Time that a Medical Hold is Placed, AOC or His/Her Designee Will Notify: 1. Medical Director at Ext or after hours, through the hospital switchboard. 2. Nurse Executive at Ext or after hours, through the hospital switchboard. 3. Children s General Counsel or designee at Ext or after hours, through the hospital switchboard. 4. Social Work Administrator On-Call (SW AOC) through the hospital switchboard. SW AOC will notify the Social Worker who is involved with the case of the decision or will ensure that a Social Worker is assigned to the case. 5. Children s Protection Program (CPP) leadership, Program Manager or SCAN Medical Consultant, at Ext or after hours, through the

3 Page 3: Clinical Policy/Procedure: Medical Hold: Temporary Protective Detention or Custody hospital switchboard by communicating directly with the oncall SCAN Medical Consultant. 6. On-Call media relations through the hospital switchboard. F. Nursing Supervisor will notify involved nursing staff of the medical hold decision and action being taken. G. The Attending Physician or SCAN Medical Consultant will document in the medical record the Medical Hold order (See Section VII below), including the discussion between the Attending Physician or SCAN Medical Consultant and the AOC and nursing supervisor. H. Child Protective Services (CPS) may detain the child until: 1. The court assumes custody, but in no case longer than 72 hours. 2. Following the assumption of custody by law enforcement agencies, CPS makes a written determination that the child's safety will not be endangered if the child is returned to the caregiver's/parent s care and custody. 3. This written documentation is placed in the patient s medical record. III. Effect of a Hold: A. While a hold is in effect, the legal decision-making authority for the child no longer rests with the parents or legal guardians. 1. Placing a hold on a child shifts the burden of protection of the child to law enforcement and CPS. 2. A medical hold requires CPS to seek court resolution of the case or to document in writing that the child is Not in danger and Is Safe to return to the parent(s) or legal guardian(s). 3. Without a hold in place, CPS must prove in court that a child Is in danger to retain custody. B. A hold is placed to prevent the child from being placed in a dangerous environment. 1. Medical Center personnel Will Not attempt to physically restrain an individual violating a hold. Contact Security STAT. Security calls or designates someone to call Law Enforcement at 911 for Immediate Assistance in these Circumstances. C. Because a hold is an interim step in evaluating a change of legal custody, Child Protective Services (CPS) and law enforcement are often reluctant to make significant care decisions that can be delayed until resolution of the custody issues. (For more information refer to Administrative P&P, Emergency Medical and Surgical Treatment including Transfusion of Blood Products for Minor Patients without Parental Consent). D. Parents or legal guardians may be allowed to resume legal decision-making at the conclusion of this process. For this reason, it may be important to provide them with information and involve them, as appropriate, in decisions until custody is determined. 1. If possible, it is advisable to seek parental consent for procedures. 2. Also, seek CPS consent for non-emergent care. IV. Care Coordination and Communication: A. Attending Physician, SCAN Medical Consultant, if involved, and the Social Worker will Evaluate:

4 Page 4: Clinical Policy/Procedure: Medical Hold: Temporary Protective Detention or Custody 1. Appropriate person to inform the caregiver/parent(s) of the medical hold. 2. Appropriate person to complete and distribute the Child Abuse/Neglect Report Form (the Black Border Form or BBF). (See Clinical P&P, Staff Roles & Responsibilities When Assessing & Reporting Concerns of Child Abuse or Neglect, Appendix: Child Abuse/Neglect Report Form (Black Border Form or BBF)). 3. Appropriate person (Social Work or Security) to complete the Clinical Action Safety Plan Evaluating Risk (CASPER) plan and form. (See Clinical P&P, Clinical Action Safety Plans Evaluating Risk (CASPERs)). 4. Appropriate person to notify law enforcement and CPS. (See Clinical P&P, Making A Child Protective Services Report). B. Within the first 12 hours after the medical hold has been initiated, the Attending Physician, Social Worker, Nursing Supervisor, Security, and CPP will review the case and determine next steps. 1. A decision to continue the patient watch will be informed by but not dictated by CPS. C. Attending Physician, Social Worker, Nursing Supervisor and Security will assist with ongoing coordination and communication of the medical and psychosocial aspects of the case among the care team, CPP, and Administration, CPS/Law Enforcement and the family including the care plan, discharge from medical hold, termination of patient watch and documentation. V. Consultation: A. Children's Protection Program (CPP) leadership (Program Manager, SCAN Medical Consultant or Program Social Work Supervisor) is available for consultation on any aspect of the medical hold process. 1. During regular weekday hours (8:00 am 4:30 pm) contact (206) After hours and on weekends contact the Medical Center's switchboard at (206) and request a SCAN Medical Consultant. (See Clinical P&P, Children s Protection Team). VI. Requirements for Documentation: A. Documentation of information about the child and the decision making process resulting in the hold and resulting from the hold will be placed into the medical record by an involved physician and other members of the patient care team justifying the need for the medical hold. B. When admitting a child under Medical Hold, the Attending Physician or SCAN Medical Consultant will document in the medical record the Medical Hold order. 1. The order can be placed in the Clincial Information System (CIS) (type Medical Hold in the order search box) or during a computer downtime on a paper order form. 2. The order should include the date and time of the medical hold. C. The Social Worker will complete and distribute the Children's Protection Team Report Form (also called the Black Border Form or BBF). D. Social Work and Security will ensure that the CASPER is continuously updated as needed.

5 Page 5: Clinical Policy/Procedure: Medical Hold: Temporary Protective Detention or Custody VII. Discontinuation of a Medical Hold: A. A hold automatically ends 72 hours after Child Protective Services (CPS) has been notified. 1. Although the hold ends, CPS may continue to maintain legal decisionmaking for the child. 2. Communication with CPS regarding the child's legal status is necessary at all stages of this process. 3. Any court order regarding legal decision-making will be placed in the medical record. B. It is recommended that hospital staff obtain a written Dispositional Statement from Child Protective Services (CPS) that delineates the discharge plan for the child. 1. The dispositional statement will explain under what circumstances the child may be discharged and to whom. 2. If the discharge time is imminent, it is recommended that the Physician or Social Worker request a faxed copy of this statement from CPS. 3. This statement will be placed in the medical record. 4. If CPS communicates its disposition decision orally, the member of the care team receiving the communication from CPS will document the contents of the oral discussion. C. The discontinuance of the Medical Hold does not necessarily mean that the CASPER and patient watch will discontinue. 1. Please refer to previously mentioned steps for decision-making (See Section IV B. and C.). D. If at any time there is a change in status regarding the hold (for example, if it is vacated either by CPS and the courts), this must be clearly documented as soon as possible in the progress notes in the medical record and verbally communicated to the care team. 1. A new order should be written by the Attending Physician and communicated to the medical and social work staff involved with the child and family. E. The Attending Physician and the Social Worker must coordinate the discharge plan and ensure that the plan is communicated to all appropriate staff members as well as to the patient s referring and primary care physician. 1. If CPS or law enforcement agents have assumed custody, they will be treated as the authorized decision-maker for the child and their instructions will be followed. 2. If Child Protective Services (CPS) and/or law enforcement has/have made the decision not to assume custody, the parents or legal guardians retain decision-making authority. 3. A new medical hold can be placed only if there are new facts that have emerged that warrant such action. F. Social Worker modifies the Clinical Action Safety Plan Evaluating Risk (CASPER) to reflect the status of the case at discharge. VIII. Immunity from Liability: A. An administrator or physician shall not be held liable in any civil action for the good faith decision to take the child into custody (RCW (3)).

6 Page 6: Clinical Policy/Procedure: Medical Hold: Temporary Protective Detention or Custody REFERENCES: RCW RCW (1)(2) RCW (3) Originated by: Reviewed by: Revised by: Children s Protection Team (Chair, Carol Jenkins, MEd) Children s Protection Program Quality Advisory Committee (Co-Chairs, Ken Feldman, MD, & Carol Jenkins, MEd) Children s Protection Team (Chair, Carol Jenkins, MEd) Mark Del Beccaro, MD, Clinical Director, Information Services, Chair, Medical Informatics/Records Review Jeff Sconyers, JD, General Counsel Approved by Medical Executive Committee: 9/06 APPROVED BY: Richard Molteni, MD Vice President & Medical Director Susan Heath, RN, MN Nurse Executive ORIGINATED: 1/05 REVIEWED: REVISED: 10/06, 12/06 Additional Key Words: Administrative Hold, CASPER, Child Protective Services, CPS, Children s Protection Team, CPT, Detain, Medical Hold, SCAN, Child Abuse, CPS, Neglect, Patient Safety, Sexual Abuse