Triage Protocol

Behavioral Support & Nursing Services On-call Services

Procedure/Protocol 1

Topic: Triage (on-call) protocol

Discussion:
1. When to call the triage nurse? The triage nurse is the only licensed
professional that can be reached after hours and is the only line that is
monitored 24/7. All other phone lines/extensions i.e. #2 Nursing
Department, #3 Behavioral Support are not monitored/answered after
hours. Messages will be returned the following business day.
a. Delegation of initial dose
b. Illness
c. Injury
d. Incident/accident i.e. falls
e. Medication error (missed dose, wrong dose, wrong time)
f. Sudden onset of confusion
g. Need for immediate medication clarification (after hours)
h. Seizure activity
i. Discharge for hospital/Urgent care
j. Elopement with injury
2. If a consumer is suspected of needing immediate, emergency medical
attention, please call 911. Nursing is not a substitute for EMS. If a nursing
evaluation is recommended by the triage RN, a nurse will evaluate the
consumer within 24 hours.
3. Call (888) 727-5659, extension 1. Please do not call extension 2 (Nursing
Department) in an attempt to reach the on-call nurse.
4. When the nurse answers your call, please state the following;
a. your name
b. group home
c. company name and what city you are calling from
d. consumer’s name
e. reason for the call.

***ALWAYS TAKE VITAL SIGNS BEFORE CALLING THE NURSE***

For example, “This is [your name], I am calling from [name of group home] with
[company name]. I am calling in regards to [consumer’s name], [reason for call].”

Behavioral Support & Nursing Services On-call Services

If the nurse does not answer the call, you must leave a voice mail. Please be sure 2
to leave the above information on the voice mail so that the nurse will be able to
return your call accurately and in a timely manner. It is rare that the on-call nurse
will not return your call within a few minutes. However, please allow the on-call
nurse 15 minutes to return your call. If the on-call nurse fails to return your call
within the allotted 15 minutes, please call again and leave your identifying
information (as stated above) a second time. If the on-call nurse fails to calls you
back within another 15 minutes, please begin calling your house managers, case
managers and/or directors until a nurse calls you back. If you feel that the situation
is more urgent and cannot wait for the on-call nurse to return your call, dial 911 for
emergency services.

Topic: When to call the Nursing Department (extension 2)

Discussion:
1. When to call the Nursing Department? The nursing department can be
reached for non-urgent, non-triage purposes.
a. Medication refills
b. Clarification of medication that does not require immediate attention
c. To leave a message for nursing staff in general
d. Elopement without injury (leave a message for nursing, follow up
nursing assessment with 24 hours of return is required)
2. Call (888) 727-5659, extension 2. Please do not call extension 2 (Nursing
Department) in an attempt to reach the on-call nurse.
3. If the call is not answered and you are prompted to leave a message, please
state the following;
a. your name
b. group home
c. company name and what city you are calling from
d. reason for the call.
4. All calls will be return within 1 business day.

Topic: When to call the Behavior Department (extension 3)

Discussion:
1. When to call the Behavior Department? The behavior department can be
reached for non-urgent purposes. All behavioral episodes and /or behavioral
concerns of a client should be directed to the provider.
a. Schedule appointment
b. Leave a message for the behavior department

Behavioral Support & Nursing Services On-call Services

2. Call (888) 727-5659, extension 3. Please do not call extension 3 (Behavior 3
Department) in an attempt to report behavioral concerns or episodes of a
client. All reports of behavioral concerns or episodes should be reported to
programming as outlined in the provider’s policy and procedure.

3. If the call is not answered and you are prompted to leave a message, please
state the following;
a. your name
b. group home
c. company name and what city you are calling from
d. reason for the call.

4. All calls will be return within 1 business day.