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2014-BHDS-006BathCountyCI

2014-BHDS-006BathCountyCI

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Published by The Washington Post
2014-BHDS-006BathCountyCI
2014-BHDS-006BathCountyCI

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Published by: The Washington Post on Mar 27, 2014
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05/15/2014

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Office of the State Inspector General Report to Governor McAuliffe and the General Assembly
Critical Incident Investigation Bath County, Virginia, November 18, 2013
March 2014
 
Michael F.A. Morehart State Inspector General
OSIG Report Number 2014-BHDS-006
 
 
Table of Contents
Executive Summary ........................................................................................................................................ i Media Reports ........................................................................................................................................... i OSIG Investigative Goals ............................................................................................................................. i Contributing Factors .................................................................................................................................. ii Recommendations.................................................................................................................................... iv The Critical Incident .......................................................................................................................................1 The Investigative Process ..............................................................................................................................2 Timeline for November 18, 2013 ..................................................................................................................5 The Family Member Contacts the RACS ....................................................................................................5 The Emergency Custody Order ..................................................................................................................6 The Notification of the RACS .....................................................................................................................9 The Preadmission Evaluation ................................................................................................................. 10 The Extension of the ECO ....................................................................................................................... 11 The Search for a Receiving Facility ......................................................................................................... 13 The Expiration of the Emergency Custody Order ................................................................................... 16 Contributing Factors ................................................................................................................................... 18 Contributing Factor No. 1 ....................................................................................................................... 18 Contributing Factor No. 2 ....................................................................................................................... 20 Contributing Factor No. 3 ....................................................................................................................... 21 Contributing Factor No. 4 ....................................................................................................................... 23 Recommendations...................................................................................................................................... 26 Recommendation No. 1a ........................................................................................................................ 26 Recommendation No. 1b ....................................................................................................................... 26 Recommendation No. 2 .......................................................................................................................... 27 Recommendation No. 3 .......................................................................................................................... 28 Recommendation No. 4 .......................................................................................................................... 28 Recommendation No. 5 .......................................................................................................................... 29 Appendix I—Complete Timeline of Events ................................................................................................. 30 Appendix II—Excerpt from Report No. 206-11 .......................................................................................... 32 Appendix III—TDO Report and Instructions ............................................................................................... 37 Appendix IV—DBHDS Guidance for Developing Regional Admission Policy and Procedures ................... 39 Appendix V—Toward a Better Understanding of Psychiatric Emergencies, Assessment for Dangerousness and Effective Interventions to Assure Safety and Enable Recovery........................................................... 43 APPENDIX VI—November 18, 2013 List of Hospital and Crisis Stabilization Unit Contacts ....................... 45

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