Source: https://www.federalregister.gov/articles/2010/11/16/2010-28711/responding-to-disruptive-patients
Timestamp: 2016-06-25 17:39:55
Document Index: 572929480

Matched Legal Cases: ['art 17', '§ 17', '§ 1', '§ 1', '§ 17', '§ 17', '§ 17', '§ 17', 'art 17', '§ 17', '§ 17', '§ 17']

Federal Register | Responding to Disruptive Patients
Dates: This final rule is effective December 16, 2010.
75 FR 69881
-69883 (3 pages)
Document Number: 2010-28711
Shorter URL: https://federalregister.gov/a/2010-28711 Related Topics
This final rule amends the Department of Veterans Affairs (VA) regulation that authorizes appropriate action when a patient engages in disruptive behavior at a VA medical facility. This amendment updates VA's current regulation to reflect modern medical care and ethical practices. The final rule authorizes VA to modify the time, place, and/or manner in which VA provides treatment to a patient, in order to ensure the safety of others at VA medical facilities, and to prevent any interference with the provision of medical care.
Responding to Disruptive Patients 4 actions from June 1st, 2010 to December 16th, 2010
75 FR 30306
This final rule is effective December 16, 2010.
Roscoe Butler, Acting Director, Business Policy, Chief Business Office (163), Veterans Health Administration, Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 461-1586. (This is not a toll free number.)
Under 38 U.S.C. chapters 17 and 18, VA has authority to provide medical care to certain veterans and non-veterans. VA is required, per 38 U.S.C. 1721, to prescribe rules and regulations to promote good conduct on the part of VA patients. VA has implemented this authority in 38 CFR part 17.
Regarding the rights of patients receiving VA care, 38 CFR 17.33(a) prescribes, in part, that patients have “a right to be treated with dignity in a humane environment that affords them both reasonable protection from harm and appropriate privacy with regard to their personal needs.” Patients also have “a right to receive, to the extent of eligibility therefor under the law, prompt and appropriate treatment for any physical or emotional disability.” Section 17.33(b) also prescribes rights with respect to visitations and communications, clothing, personal possessions, money, social interaction, exercise, and worship for VA residents and inpatients. These rights may be restricted by the appropriate health care professional in certain circumstances. See 38 CFR 17.33(c). The restrictions authorized by § 17.33(c), however, do not apply to outpatients and only cover restrictions on the listed rights. In certain cases, VA must restrict the provision of medical care to a patient in order to prevent harm to other patients and VA staff and disruptions in VA's provision of medical care due to the patient's behavior.
VA regulations also prescribe rules of conduct for patients and other individuals who have access to VA facilities. See 38 CFR 1.218. In particular, § 1.218(a)(5) prohibits persons on VA property from causing a wide variety of disturbances, including creating “loud or unusual noise,” obstructing public areas, and impeding or disrupting “the performance of official duties by Government employees.” The sole enforcement mechanism provided by paragraph (a)(5) is “arrest and removal from the premises.” 38 CFR 1.218(a)(5). VA has determined that arrest is generally not an appropriate remedy in a situation where the Department must balance the rights and needs of a disruptive patient against the need to protect other patients, guests, and staff. Some patients establish a pattern of disruptive behavior when interacting with VA personnel or when they are on VA property, and we believe that by understanding these patterns of behavior, planning for such behavior in advance, and setting safe conditions for care delivery, we can intervene in ways that can prevent subsequent episodes requiring removal and arrest.
In addition to §§ 1.218 and 17.33, the behavior of patients is specifically governed by current 38 CFR 17.106. It requires, in part, that VA maintain the good conduct of patients through “corrective and disciplinary procedure.” However, current § 17.106, which VA promulgated in 1973 and last amended over 10 years ago, does not adequately reflect modern practice or VA's policy regarding disruptive patients in the health care setting, which opposes the use of punishment in the management of disruptive patients. Instead, it reflects the view that patients exhibiting disruptive behavior must be punished. For example, current § 17.106 emphasizes disciplining patients who do not engage in “good conduct,” and includes measures (such as withholding pass privileges) that do not differentiate between providing care and ensuring the safety of others. Moreover, the current rule could be viewed as interfering with VA's legal obligation to provide medical care to certain veterans and non-veterans. Accordingly, VA has determined that amendments to current regulations are necessary to implement its policy regarding disruptive patients, which emphasizes continuation of treatment.
On June 1, 2010, we proposed to amend § 17.106 to prescribe the remedial measures VA will take when a patient is disruptive and the procedures for implementing those measures. 75 FR 30,306. We stated that our intent was to minimize the risk of a particular patient jeopardizing the health or safety of others, or disrupting the safe provision of medical care to another patient, in a VA medical facility. We received three comments on the proposed rule. All of the commenters supported the proposed rule, and there were no adverse comments on the content of the proposed regulation text or on the rationales for the regulation text that we had provided in the notice of proposed rulemaking.
The first commenter agreed that the proposed rule “indicate[s] a total care for other patients [sic] safety, as well as the disruptive patient's safety.” The commenter agreed that the regulations, being “more extensive and unique to the acts of disruptive behavior,” may lead to improvements for VA facilities. The commenter suggested that “speaking with a disruptive patient * * * could eliminate the issue from happening again to someone else.” Although the regulation does not specifically require direct verbal communication with a disruptive patient, the regulation requires VA to provide the patient with notice of the content of any order responding to the patient's behavior, and clearly contemplates clinical involvement, including patient-specific communication. To the extent that the commenter offers a way for VA to improve generally the manner in which we respond to disruptive patients in order to eliminate future disruptions, we agree and note that we have established Disruptive Behavior Committees (DBCs) specifically for this purpose. These DBCs will review instances of disruptive behavior and make appropriate recommendations. Thus, we make no changes based on this comment.
Another commenter agreed that withholding visitation rights or any other restriction, as was authorized by the prior version of § 17.106, may be unethical. The final rule does not contemplate such punitive measures, and furthermore, paragraph (b)(2) of the final rule requires that any restrictions on the time, place, or manner of patient care must be “narrowly tailored.” The commenter added that “any action taken against the patient should be handled clinically” by an appropriate medical professional. We agree, and note that the final rule requires that the VA medical facility Chief of Staff or his or her designee, which will in all cases be a clinical professional, authorize all actions taken in regards to a disruptive patient. As stated in the proposed rule, the new regulatory procedure will emphasize addressing the disruptive patient's needs in order to advance VA's focus on patient care. Thus, we make no changes based on this comment.
The third and final commenter, speaking for The Joint Commission, supported the regulation and did not offer any suggestions for improvement. The Joint Commission approved of the regulation because it is in accordance with their own criteria concerning the rights and responsibilities of patients and the environment in which care is provided. We appreciate the comment, and have not made any changes based on it.
For the foregoing reasons, VA amends 38 CFR 17.106 as proposed in the June 1, 2010, notice of proposed rulemaking published at 75 FR 30,306.
Title 38 of the Code of Federal Regulations, as revised by this rulemaking, represents VA's implementation of its authority on this subject. Other than future amendments to this regulation or governing statutes, no contrary guidance or procedures on this subject are authorized. All VA guidance must be read to conform with this rulemaking if possible or, if not possible, such guidance is superseded by this rulemaking.
The Unfunded Mandates Reform Act requires, at 2 U.S.C. 1532, that agencies prepare an assessment of anticipated costs and benefits before developing any rule that may result in the expenditure by State, local, or tribal governments, in the aggregate, or by the private sector, of $100 million or more (adjusted annually for inflation) in any given year. This final rule will have no such effect on State, local, or tribal governments, or on the private sector.
The economic, interagency, budgetary, legal, and policy implications of this final rule have been examined and it has been determined not to be a significant regulatory action under the Executive Order.
The Secretary hereby certifies that this final rule will not have a significant economic impact on a substantial number of small entities as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601- 612. This final rule will not cause a significant economic impact on health care providers, suppliers, or entities since only a small portion of the business of such entities concerns VA beneficiaries. Therefore, pursuant to 5 U.S.C. 605(b), this final rule is exempt from the initial and final regulatory flexibility analysis requirements of sections 603 and 604.
The Secretary of Veterans Affairs, or designee, approved this document and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs. John R. Gingrich, Chief of Staff, approved this document on November 3, 2010 for publication.
1.Revise the authority citation for part 17 to read as follows: Authority:
2.Revise § 17.106 to read as follows: § 17.106 VA response to disruptive behavior of patients.
(a) Definition. For the purposes of this section:
(b) Response to disruptive patients. The time, place, and/or manner of the provision of a patient's medical care may be restricted by written order of the Chief of Staff of the VA Medical Center of jurisdiction or his or her designee if:
(c) Evaluation of disruptive behavior. In making determinations under paragraph (b) of this section, the Chief of Staff or designee must consider all pertinent facts, including any prior counseling of the patient regarding his or her disruptive behavior or any pattern of such behavior, and whether the disruptive behavior is a result of the patient's individual fears, preferences, or perceived needs. A patient's disruptive behavior must be assessed in connection with VA's duty to provide good quality care, including care designed to reduce or otherwise clinically address the patient's behavior.
(d) Restrictions. The restrictions on care imposed under this section may include but are not limited to:
(e) Review of restrictions. The patient may request the Network Director's review of any order issued under this section within 30 days of the effective date of the order by submitting a written request to the Chief of Staff. The Chief of Staff shall forward the order and the patient's request to the Network Director for a final decision. The Network Director shall issue a final decision on this matter within 30 days. VA will enforce the order while it is under review by the Network Director. The Chief of Staff will provide the patient who made the request written notice of the Network Director's final decision.
Note to § 17.106:
[FR Doc. 2010-28711 Filed 11-15-10; 8:45 am]