OREGON STATE HOSPITAL POLICIES AND PROCEDURES

SECTION 6: Patient Care POLICY: 6.066

SUBJECT: Isolation of Patients Under Investigation for or Confirmed Positive for Serious, Highly Infectious Diseases

POINT CHIEF MEDICAL OFFICER PERSON:

APPROVED: DOLORES MATTEUCCI DATE: APRIL 27, 2020 SUPERINTENDENT

I. POLICY A. The purpose of the policy for isolation of patients is to provide for medically necessary preventative measures to protect the patient and avoid an outbreak of highly infectious diseases. B. This policy applies to all staff, including employees, volunteers, trainees, interns, contractors, vendors, and other state employees assigned to work at OSH. C. OSH follows all applicable regulations, including federal and state statutes and rules; Oregon Department of Administrative Services, Shared Services, and Oregon Health Authority policies; and relevant accreditation standards. Such regulations supersede the provisions of this policy unless this policy is more restrictive. D. Staff who fail to comply with this policy or related procedures may be subject to disciplinary action, up to and including dismissal.

II. DEFINITIONS “Chief Medical Officer or Designee” means the designated Chief Medical Officer for the Oregon State Hospital or a person the CMO designates in their absence to order isolation as defined in this policy, and who is a physician licensed to practice medicine in the State of Oregon, or a licensed psychiatric/mental health nurse practitioner. “Isolation” means the involuntary placement of a patient, who is suspected of or is diagnosed with a serious, highly infectious disease, alone in a locked room or area when it is medically necessary to prevent the spread of that infectious disease to other patients or staff. Isolation is not a form of restraint. SUBJECT: Isolation of Patients POLICY NUMBER: 6.066 DATE: April 27, 2020 Page 2 of 3

“Serious, Highly Infectious Disease” means a communicable disease which is widely considered highly contagious, and which may lead to serious health consequences for a patient, including death.

III. PROCEDURES When there is reason to believe that a patient has been exposed to or has contracted a serious, highly infectious disease, the following procedures shall be followed: A. Staff shall medically assess the patient for symptoms of the particular serious, highly infectious disease. Depending on the suspected disease, this could include temperature, blood pressure, pulse, assessment of breathing. B. Staff shall attempt to obtain agreement from the patient or guardian for the patient to remain in a designated room or area and, if medically reasonable, to follow necessary safety protocols to prevent the spread of the infectious disease. If informed consent is obtained from the patient or guardian, it shall be recorded in the patient’s chart. C. If the patient or guardian for the patient do not agree to follow preventative measures, staff shall immediately seek an order for the patient’s involuntary placement in isolation from the Chief Medical Officer or Designee. D. The Chief Medical Officer or Designee may order a patient’s involuntary placement in isolation if: 1. The patient is suspected of or is diagnosed with a serious, highly infectious disease; 2. The patient refuses to or is unable to remain in an unlocked room or area, or refuses to or is unable to follow staff’s instructions related to necessary safety protocols; and 3. Isolation of the patient is temporarily necessary to prevent the spread of the infectious disease to other patients and staff. E. The following procedures shall be followed when the Chief Medical Officer or Designee orders isolation of a patient to prevent the spread of the serious, highly infectious disease: 1. The CMO or designee shall give a telephone or written order for isolation which shall be documented in the patient’s chart. 2. The order shall last only as long as it is medically necessary to prevent the spread of the infectious disease to other patients and staff, as determined by the Chief Medical Officer or Designee. 3. The Chief Medical Officer or Designee shall review the continued need for the isolation order every 72 hours, and document the continued need for isolation in the patient’s chart. SUBJECT: Isolation of Patients POLICY NUMBER: 6.066 DATE: April 27, 2020 Page 3 of 3

F. During the patient’s isolation, the state institution shall ensure that its staff: 1. Perform checks on the patient every 1 hour and such checks must be documented in the patient’s chart; a. Checks shall be performed by visually observing the patient from outside of their room. b. If the patient is awake, checks are encouraged to include verbal communication concerning the patient’s personal needs and in accordance with general medical practice; c. If the patient is asleep, checks may be made without waking the patient, provided that staff has no concerns regarding the patient’s physical safety; d. The Chief Medical Officer or Designee or treating physician may require additional protocols be followed for an individual patient based on their clinical condition (e.g., additional checks), which will be documented in patient’s chart; 2. Attend to the patient’s basic personal needs and exercise needs in accordance with general medical practice and consistent with maintaining medically necessary isolation; and 3. To the extent practicable and medically safe to other patients and staff, accommodate treatment for the patient’s mental disorder.

IV. REFERENCES 42 CFR § 482.42. Centers for Medicare and Medicaid. Waiver (1135) for 42 CFR 482.13(e)(1)(ii). Retrieved from https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf. Oregon Administrative Rule 309-112-0000 —112-0035. Oregon State Hospital Infection Prevention Protocol. Hospital control measures for communicable disease outbreaks, 4.080. Author. Oregon State Hospital Infection Prevention Protocol. Infection prevention program, 1.010. Oregon State Hospital Policy and Procedure Manual. Infectious disease management in health care personnel, 2.003. Author.