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Findings and Recommendations 6 findings
F1
The complainant was admitted to the San Luis Obispo County Psychiatric Health Facility at 1:13 AM on a Saturday morning in October 2007 acting irrationally. He was released about 9 AM that same morning, was coherent and functioning well enough to be safely taken home by a friend.
No recommendations for this finding
F2
The San Luis Obispo County Psychiatric Health Facility has in place a policy prescribing that mental patients who have “ingested alcohol and/or more medications than directed, or any person suspected of having ingested any of these substances” should be sent to an emergency room.
No recommendations for this finding
F3
The patient in this case communicated to the health facility staff minutes after his admission that he’d been using a prescribed pain medication patch hours before he was determined to be a danger to himself or others.
No recommendations for this finding
F4
This patient was not taken to a hospital emergency room.
Related Recommendations (1)
R1
The County Psychiatric Health Facility should review how its policy of taking possible drug overdose patients to the emergency room is implemented. The results of that review should be reported to the Board of Supervisors within three months to assure patient protection.
F5
The Health Facility routinely allows video records showing the behavior of isolated 5150 patients to be erased after 30 days. _____________________________________________________________________________ 5
Related Recommendations (1)
R2
The Psychiatric Health Facility should retain for at least two years the video records of 5150 patients’ isolation room behavior, as a way both of assuring appropriate treatment of patients and of protecting the county in the case of legal action.
F6
Mental health department officials say that it takes them too long under current conditions to receive results of a toxicology screen.
Related Recommendations (1)
R3
Mental Health officials must assure that speedy toxicology screens are available when needed, with a stated policy that requires such action.
Conclusions 1
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CL1Our complainant apparently suffered a serious psychotic episode as a result of an overdose of a dangerous prescribed pain medication. Transported by police to a local psychiatric health facility, he was evaluated, isolated and observed through the night. The next morning he was released to go home. He asserts that his treatment by the psychiatric health facility was abusive, degrading and could have placed his life in danger. The Grand Jury has no evidence to support that conclusion beyond the known problems with some pain medication patches and the facility record indicating he was allowed to defecate on himself. Mental Health Facility policy declares _____________________________________________________________________________ 2008-2009 San Luis Obispo County Grand Jury 4 that mental patients who have “ingested alcohol and/or more medications than directed” should be sent to an emergency room. . In this case, the Mental Health facility staff members, in their professional opinion, did not feel the patient met the requirements for transport to an emergency room for a medical clearance. After careful and extensive review, the Grand Jury wonders if this patient could have benefited from a medical evaluation and possible treatment at an emergency room. At the very least, the Grand Jury would recommend a careful review and clarification of the use of this protocol. The Grand Jury also recommends that the facility retain video records of patients kept in isolation on a 5150 hold be retained for two years and that officials at the facility make sure they have access to timely results of toxicology tests.
Agency Responses 1
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No Responses Found 1
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San Luis Obispo County Board of Supervisors
Elected County Office