El Dorado County Grand Jury • 2010-2011

El Dorado County Grand Jury 2010-2011 Mental Health Detention Policy and Procedures Case Number Gj010-009

Published: October 25, 2010 9 pages
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Findings and Recommendations 9 findings

F1
A major causal factor in the March 2010 incident was the fact that previous to March 2010, attention to detail and awareness of the agencies involved in the care and observations of 5150 patients had lapsed.
Related Recommendations (1)
R1
The Mental Health Division of the El Dorado County Health Services Department should be the lead agency in an annual reminder of the March 2010 incident and training for all agencies involved in the care and monitoring of 5150 patients. MARSHALL MEDICAL CENTER SECURITY
F2
The March 2010 incident shed light on the oversight of the agencies that relate to 5150 patients. MARSHALL MEDICAL CENTER SECURITY
Related Recommendations (1)
R2
Coordination and communication between hospital personnel and the security guards is essential. All Marshall HSS security personnel should be trained to deal with mentally impaired patients.
F3
Hospital security, as currently provided by HSS, is marginally adequate. There is only one officer with law enforcement training. The other security officers were not extensively trained when hired and their training has not been updated.
Related Recommendations (1)
R3
HSS security staff needs training in documenting important events that occur on their shifts related to the monitoring of 5150 patients. All daily security notes regarding 5150 patients should be provided to the Charge Nurse.
F4
The HSS Supervisor at Marshall spends a significant portion of his day doing administrative work and attending meetings. This leaves the only other day shift officer alone to deal with both the ordinary security functions as well as 5150 surveillance. In addition, the supervisor is the only designated on call person in case of an emergency.
Related Recommendations (1)
R4
The purpose, current usage and configuration of the video monitoring system should be re-evaluated. The current system must be upgraded if it is going to be of any use in preventing another incident. AMBULANCE
F5
Currently, hospital staff and HSS officers provide continuous 5150 patient observation within the emergency department. However, Marshall Medical Center is not a designated mental health facility with a locked, secure area for 5150 patients.
Related Recommendations (1)
R5
The Executive Director of the El Dorado County Emergency Medical Authority has proposed changes to the Ambulance 5150 policy that are intended to reduce the likelihood that a patient would harm themselves or others. The proposed changes should be reviewed by other agencies; especially Marshall Medical Center, which has policies and procedures for transporting persons with mental health issues. MULTI-DISCIPLINARY TEAM
F6
Hospital security failed to document important events and information from their shifts.
Related Recommendations (1)
R6
Marshall Medical Center, Healthcare Security Services officers, Director of the Emergency Services Authority, and USDA Forest Service Law Enforcement should be included in MDT training. EL DORADO COUNTY
F7
The video camera system is inadequate. There are areas in the Marshall Emergency Department that are not covered by cameras. The video recordings are retained for one week. AMBULANCE
Related Recommendations (1)
R7
El Dorado County should have a designated health facility where 5150 patients and others with mental health impairments would be evaluated and treated in a safe, secured environment. RESPONSES Responses to findings and recommendations in this report are required in accordance with the California Penal Code §933 and §933.05. Address responses to: The Honorable Suzanne N. Kingsbury, Presiding Judge of the El Dorado County Superior Court, 1354 Johnson Blvd., South Lake Tahoe, CA 96150. This report has been provided for a response to the following agencies:  Director, Health Services Department, 670 Placerville Drive Suite 1B, Placerville, CA 95667  Chief Executive Officer, Marshall Medical Center, 1100 Marshall Way, Placerville, CA 95667  Healthcare Security Services Supervisor, Marshall Medical Center, 1100 Marshall Way, Placerville, CA 95667  Executive Director, Emergency Services Authority, 480 Locust Road, Diamond Springs, CA, 956667  El Dorado County Sheriff, 300 Fair Lane, Placerville, CA 95667  Chief, Placerville Police Department, 730 Main Street, Placerville, CA 95667  Chairperson, El Dorado County Board of Supervisors, 330 Fair Lane, Placerville, CA 95667  Patrol Captain, El Dorado National Forest, 100 Forni Road, Placerville, CA, 95667 Elected officials under statute are given 60 days to respond, and non-elected officials are provided a 90-day response period from the release date of this report.
F8
As of October 25, 2010, revisions to the ambulance policy have been under discussion. Proposed changes would require that all 5150 patients riding in El Dorado County Emergency Service Authority vehicles be secured. Gravely disabled and incapacitated patients would be secured with gurney straps. Patients, who have a history of violence or are violent, agitated or angry, coupled with the physical capability of inflicting harm and endangering themselves, would be placed in a four-point restraint. MULTI-DISCIPLINARY TEAM
No recommendations for this finding
F9
Marshall Medical Center, Healthcare Security Services officers, Director of the Emergency Services Authority, and the USDA Forest Service Law Enforcement has expressed an interest in participating in the MDT.
No recommendations for this finding

No Responses Found 3

Government entities assigned to respond to this report. No response documents have been linked in our database.

County of El Dorado Agency
El Dorado County Sheriff Elected County Office
Placerville City