CHAPTER: 800 INMATE MANAGEMENT		OPR: OPS PS
DEPARTMENT ORDER MANUAL		DEPARTMENT ORDER: 807 INMATE SUICIDE PREVENTION, PRECAUTIONARY WATCHES AND CLINICALLY ORDERED RESTRAINTS		SUPERSEDES:  DI 22 (04/11/06), DI 244 (06/08/06)
				EFFECTIVE DATE:     July 19, 2006

 TABLE OF CONTENTS

This Department Order establishes standards and procedures for the prevention of inmate suicide by Department staff.

This Department Order applies to all Department staff who directly or indirectly supervises the inmate population.

807.01     TRAINING

1.1    Pre-Service Training, Correctional Series Staff - All correctional series staff shall receive training in the identification and management of suicidal inmates in accordance with this Department Order. Pre-service training shall include:

1.1.1    Eight hours of suicide prevention/mental health instruction. Instruction may be provided at the Institutional Regional Academies or at the Correctional Officer Training Academy (COTA). Mental health and correctional staff shall jointly provide instruction. Suicide prevention/mental health instruction shall include mock drills, information presentation, and practice in applying clinically ordered restraints.

1.1.2    Mock Drills consisting of:

1.1.2.3    Location of rescue tool/cut down instrument.

1.1.2.4    Cut down practice using body-sized and weighted object.

1.1.2.5    Positioning of body-sized object for emergency medical treatment.

1.1.2.6    Notification of medical and mental health staff.

1.1.3    Detailed information about inmate suicide and suicide prevention including:

1.1.3.1    How to identify inmates who may be at risk for suicide.

1.1.3.2    How to identify high risk times, locations, and methods for suicide.

1.1.3.3    How to identify incidents and situations that may trigger a suicide attempt.

1.1.3.4    How to identify possible signs of suicidal intent.

1.1.3.5    The role of Department staff in preventing inmate suicide and the Department's policy on inmate suicide prevention.

1.1.3.6    Staff will keep on their person a Department issued Suicide Prevention Card.

1.1.3.6.1    Staff will familiarize themselves with the four sections of the card.

1.1.3.6.2    Staff will refer to this card as an aide in the identification of suicide warning signs.

1.1.3.7    Staff conduct required in the event of a suicide attempt.

1.1.3.8    Staff conduct required after an inmate death by suicide.

1.1.4    Detailed information about clinically-ordered restraints for serious self-injurious behavior and practice in applying restraints, including:

1.1.4.1    Guiding principles for clinically ordered restraints.

1.1.4.3    Practice in the application of clinically ordered soft restraints.

1.2    Pre-Service Training, Other Staff - All non-correctional series staff shall be trained in the identification and management of suicidal inmates in accordance with this Department Order. Pre-service training shall include the following:

1.2.1    Two hours of suicide prevention/mental health instruction.

1.2.2    Detailed information about inmate suicide and suicide prevention including:

1.2.2.1    How to identify inmates who may be at risk for suicide.

1.2.2.2    How to identify high risk times, locations, and methods for suicide.

1.2.2.3    How to identify incidents and situations that may trigger a suicide attempt.

1.2.2.4    How to identify possible signs of suicidal intent.

1.2.2.5    The role of Department staff in preventing inmate suicide and the Department's policy on inmate suicide prevention.

1.2.2.6    Conduct required in the event of a suicide attempt.

1.2.2.7    Conduct required after an inmate death by suicide.

1.2.2.8    Liability issues associated with inmate suicide.

1.2.2.9.    Staff will keep on their person a Department issued Suicide Prevention Card.

1.2.2.9.1    Staff will familiarize themselves with the four sections of the card.

1.2.2.9.2    Staff will refer to this card as an aide in the identification of suicide warning signs.

1.2.3    Health and mental health staff shall also be instructed on clinically-ordered restraints for serious self-injurious behavior and shall participate in mock drill training.

1.3    Annual Refresher Suicide Prevention Training - All correctional series staff and staff assigned to institutional units shall receive annual Refresher Suicide Prevention training to include the following:

1.3.1    Two hours of annual training.

1.3.2    How to identify inmates who may be at risk for suicide.

1.3.3    How to identify high risk times, locations, and methods for suicide.

1.3.4    How to identify incidents and situations that may trigger a suicide attempt.

1.3.5    How to identify possible signs of suicidal intent.

1.3.6    Review of all changes to the Department's suicide prevention policy or procedures.

1.3.7    Discussion of experiences learned from any recent suicides and/or suicide attempts in the Department.

1.4    Annual Refresher Training for Clinically Ordered Restraint

1.4.1    All staff who applies clinically ordered restraints must successfully complete annual refresher training in the application of clinically ordered restraints.

1.5    Basic First Aid and Cardiopulmonary Resuscitation (CPR) Training - All staff having regular contact with inmates shall successfully complete basic first aid and CPR training and refresher training as needed to remain certified.

1.6    At least quarterly Wardens shall:

1.6.1    Incorporate into training programs, scenarios that require emergency response within the three minute time limit as described in section 807.07, 1.1.

1.6.2    Conduct detailed exercises and drills that test staff response time to hypothetical situations including realistic mock suicide drills.

1.7    The Staff Training Bureau shall incorporate intervention standards into all applicable lesson plans and curricula.

807.02     SCREENING, ASSESSMENT, AND CLASSIFICATION

1.1    A Transfer Summary/Continuity of Care (TSCC) form (or electronically transmitted equivalent) identifying any medical, mental health, and suicide risk needs shall be provided by the transferring agency; that is, jails, for any inmate processed through the Department’s reception centers.

1.1.1    In the event that a TSCC form (or electronically transmitted equivalent) is not provided, the transferring agency shall be contacted by medical staff to provide the information. A log shall be kept by medical staff of all inmates arriving without a TSCC form (or electronically transmitted equivalent) or with an inadequately completed form for the purpose of quality assurance. This log will be filed with the Facility Health Administrator who shall use it to evaluate the accuracy and reliability of continuity of care information provided to the reception center.

1.1.2    All inmates processed through the Department’s reception centers shall be administered the Mental Health Assessment, Form 1103-27, by the mental health staff within one working day of his/her arrival.

1.2    Return-to-custody inmates (revoked release violators) shall be administered the Mental Health Assessment Form by mental health staff as soon as feasible but no later than one working day after arrival.

1.3    New admissions and return-to-custody inmates arriving on psychotropic medications and/or with a mental health or suicide history shall be asked to sign an authorization to disclose health and/or mental health records from outside providers within one working day of arrival. Refusal of authorization shall be noted in the inmate medical record. Medical and mental health staff shall make a reasonable effort to obtain prior health and mental health inpatient and outpatient records. Requests for prior records shall be made within ten working days of arrival.

1.4    Whenever an inmate is identified as at significant risk for suicide by any means including self-report, nonverbal behavior, historical information, or information from any other individual, the inmate shall be referred immediately to mental health staff for further assessment, treatment, and/or placement on suicide watch.

1.4.1    During non-business hours including nights or holidays, the referral shall be made to nursing staff and the scheduled Mental Health Urgent Responder.

1.5    Suicide risk assessment shall include but not be limited to the following:

1.5.1    Triggers for prior self-harm such as loss of relationship, isolation, threats or perceived threats from others.

1.5.2    Suicide risk factors including previous suicide attempts, family members who have attempted or completed suicide, history of depression or other mental health problems, history of chronic substance abuse or dependence, history of serious medical problems or medical problems affecting body image or lifestyle, history of violence and poor coping skills.

1.5.3    Signs of suicidal intent; as examples inflicting self-injury, communicating suicidal intent or plan, making final arrangements, hopelessness, depression, anxiety/apprehension, social withdrawal, unexpected or unexplained improvement in mood after a period of depressed mood, disorientation, unusual or disorganized thinking, anger/hostility, agitation, under the influence of mind or mood altering substances.

1.5.4    Level(s) of lethality of prior acts of self-harm.

1.5.5    Mental status examination.

1.5.6    Current medications.

 

1.5.7    Current psychiatric diagnosis.

1.5.8    Recommendations/treatment plan.

1.5.9    Staff may not rely entirely on an inmate’s denial of suicide risk when the inmate’s behavior, mental health status, history, or information from other sources suggest otherwise.

1.5.10    Suicide risk assessments shall be documented in the mental health section of the medical record.

1.6    Any history of serious self-harm or suicide attempts shall be clearly documented on the Problem List contained in the inmate's medical record.

1.7    Inmates with any known history of serious self-harm will be designated as a Mental Health Needs score of 3 S (Special Need) throughout their incarceration.

1.7.1    Serious self-harm is defined as self-injury involving potentially lethal methods, e.g., hanging, overdose involving lethal substances, or methods that were likely to be potentially lethal considering the time of day, setting, degree of staff supervision, or likelihood of rescue or intervention e.g., cutting attempts occurring in the middle of the night.

1.7.2    A change in designation for these inmates to R (Routine Need) must be approved in writing by the Mental Health Program Manager.

1.1    All Department staff shall:

1.1.1    Remain aware of the issue of suicide risk, share pertinent information with appropriate mental health and security staff, and make referrals as needed to mental health and security staff.

1.1.2    Have on their person while on duty the suicide prevention card issued to them.

1.1.3    Immediately notify their supervisor and the shift commander when an inmate communicates or displays signs of suicidal intent or when an inmate demonstrates bizarre or unusual behavior.

1.1.4    Stay with the inmate, actively listen, and maintain contact through conversation, eye contact, and body language when immediate risk of self-harm is present.

1.1.5    Document in an Information Report inmate communications or other observed signs of suicidal intent or observed bizarre or unusual behavior.

1.2    The shift commander shall:

1.2.1    Immediately notify mental health staff of the potentially suicidal or mentally disordered inmate.

1.2.2    During non-business hours including nights and holidays contact nursing staff and the scheduled Mental Health Urgent Responder.

1.2.3    In the event mental health staff cannot be contacted, place the inmate on a continuous suicide watch after obtaining approval from the On-Call Duty Officer until mental health staff is contacted.

1.3    Mental health staff shall complete the Mental Health Disposition, Form 1103-44, identifying the type and frequency of the inmate's watch checks, as well as other conditions of the watch e.g., safety (suicide) blanket, safety (suicide) smock, clothing, personal property, types of meals, etc.

1.3.1    During non-business hours including nights and holidays, health care staff in consultation with the Mental Health Urgent Responder shall complete the Mental Health Disposition form.

1.3.2    One yellow copy of the Mental Health Disposition form shall be provided to security staff with the second copy being filed in the mental health record.

1.4    The Deputy Warden shall ensure that the shift commander:

1.4.1    Initiates an Observation Record, Form 1101-16, when an inmate is placed on suicide or mental health watch.

1.4.2    Places a yellow copy of the Observation Record on or adjacent to the watch cell door along with a yellow copy of the Mental Health Disposition form.

1.4.3    Ensure staff updates the Observation Records for all watch-check inmates according to the frequency indicated on the Mental Health Disposition form.

1.4.4    Collects completed Observation Records at the end of each shift for his/her signature.

1.4.5    Forwards signed and completed Observation Records to the inmate’s institutional file for retention.

1.4.6    Makes any necessary notifications in accordance with Department Order #105, Information Reporting System, and completes and distributes a Use of Force/Incident Management Report, Form 804-2 and a Significant Incident Report (SIR), Form 105-3 as appropriate.

1.4.7    Maintains and updates a daily log of all inmates on suicide or mental health watch. The log shall be distributed to the unit Deputy Warden, health staff, and mental health staff.

1.4.8    Informs assigned security staff of the status of each inmate on suicide or mental health watch through shift briefings and other means.

1.4.9    Transmit a copy of the Mental Health Disposition and the Observation Record with the inmate in the event the inmate is transferred to the hospital or to another unit while still on suicide or mental health watch.

1.5    In the event an inmate is transferred to the hospital or to another unit while on suicide or mental health watch, the Key Contact Psychologist (Psychologist III or Clinical Director) or designee shall contact the receiving facility to inform staff of the inmate's watch status and the reasons for the watch.

1.1    All housing units/cell blocks/living areas, with and without precautionary watch cells, shall contain emergency equipment, including first aid kit, pocket mask or face shield, and an emergency cut down tool. The Deputy Warden shall ensure that such equipment is always available and in working order.

1.1.1    Emergency equipment in all housing units/cell blocks shall be located and available for utilization within the three-minute time limit. (See Section 807.07.)

1.2    Inmates placed on suicide or mental health watch shall be housed in designated watch cells having high visibility to staff.

1.2.1    All designated watch cells shall be as suicide-resistant as is reasonably possible, free of all obvious protrusions and tie-off points, and provide full visibility.

1.2.2    Designated cells shall be inspected quarterly by the responsible Key Contact Psychologist or designee to ensure they continue to be as suicide-resistant as is reasonably feasible.

1.3    Prior to inmate placement in or return to a watch cell, security staff shall search the cell and remove all extraneous objects, including especially any item that could be used in a self-harm attempt.

1.3.1    When removed from a watch cell, prior to returning the inmate to the cell he/she shall be searched for any items which could potentially be used for self-harm.

1.4    For suicide watch (a watch for inmates presenting significant suicide risk or actively engaged in self-harm), inmates shall be provided with a minimum of two safety blankets, a safety smock, a suicide-resistant mattress and a small supply of toilet paper (i.e., a strand no longer 12 inches or approximately three squares) minus the cardboard roll.

1.4.1    Whenever clothing is removed from a suicidal inmate, he/she shall be issued a safety smock. No inmate may be placed or kept in a cell naked at any time.

1.4.2    Any additional items provided to the inmate shall be pre-approved by mental health staff.

1.4.2.1    The maximum allowed items for suicide watch include jumpsuit, undergarments, unlaced footwear, writing and reading materials, spork and personal hygiene items (i.e., soap, tooth paste, tooth brush).

1.4.2.2    Razors, razor blades, towels, sheets, belts, shoe laces, and electronic appliances shall not be approved for suicide watches.

 

1.4.2.3    Mental health staff shall approve additional items only when deemed safe and clinically appropriate.

1.4.3    Physical restraints shall be avoided whenever possible and used only as a last resort when the inmate is physically engaging in self-destructive behavior. Metal handcuffs shall never be utilized for restraint.

1.4.4    Unless contraindicated by mental health staff, each inmate on suicide watch shall be afforded showers, telephone privileges, recreation, and visitation in accordance with his/her custody level.

1.5    For mental health watch (a watch for inmates demonstrating acute signs or symptoms of significant mental disorder but not at significant suicide risk), inmates shall be provided with a minimum of one set of personal clothing (excluding belts and shoelaces), regular bedding, personal hygiene items (excluding razors or razor blades), toilet paper, mattress, and reading and writing material.

1.5.1    Any additional items provided to the inmate shall be pre-approved by mental health staff.

1.5.1.1    The maximum allowed items for mental health watch include one set of personal clothing, undergarments, footwear, regular bedding, towel, writing and reading materials, regular eating utensils, one small electronic sound appliance (i.e., Walkman, battery-operated radio, with earphones) and personal hygiene items (i.e., soap, tooth paste, tooth brush).

1.5.1.2    Razors and razor blades shall not be approved for mental health watches.

1.5.1.3    Mental health staff shall approve additional items only when deemed safe and clinically appropriate.

1.5.2    Unless contraindicated by mental health staff, each inmate on mental health watch shall be afforded showers, telephone privileges, recreation, and visitation in accordance with his/her custody level.

1.6    Inmates shall never be placed on suicide or mental health watch as a disciplinary sanction or as a means to address problematic inmate behavior unrelated to mental health issues.

1.7    Any deviations from the above suicide or mental health watch conditions require prior approval from the Mental Health Program Manager in consultation with Offender Operations.

807.05    LEVELS OF OBSERVATION

1.1    Closed-circuit television monitoring or use of suicide prevention aides shall never substitute or replace in-person visual checks by security staff, although they may be used to supplement observation.

1.1.1    Suicide prevention aides are inmates who have been screened, trained and hired to supplement staff observation and facilitate the Department's suicide prevention efforts.

1.2    Mental Health Watch:

1.2.1    Mental health watch is a precautionary watch for inmates suffering from acute mental health issues but who are not deemed by mental health staff to be at significant suicide risk. It provides closer and more structured observation for inmates whose mental status could deteriorate or who could become suicidal.

1.2.2    Mental Health Watch is warranted when an inmate is demonstrating acute signs or symptoms of significant mental disorder, but is determined by mental health staff as not being at imminent risk for suicide.

1.2.3    Mental health staff shall immediately complete an assessment whenever an inmate is placed on mental health watch.

1.2.3.1    If an inmate is placed on mental health watch during non-business hours including nights or holidays, mental health staff shall complete a mental health assessment no later than the next working day.

1.2.4    Mental health staff shall evaluate the inmate at least once per day he/she is on the mental health watch.

1.2.4.1    During non-business hours including nights or holidays, medical staff shall evaluate the inmate on mental health watch at least once each day.

1.2.5    When pre-approved by both security and mental health staff, inmates on mental health watch may be double-bunked.

1.2.5.1    Inmates on mental health watch may only be double-bunked after review of pertinent inmate data by security staff and review of the mental health record by mental health staff. Security and mental health staff shall consult one another regarding a decision to double-bunk inmates on mental health watch.

1.2.5.2    Inmates on mental health watch shall never be double-bunked by a Mental Health Urgent Responder.

1.2.5.3    Inmates shall never be double-bunked on mental health watch when there are concerns about safety and security issues posed by security or mental health staff.

1.2.5.4    The decision to double-bunk inmates on mental health watch shall be described and documented in the mental health record.

1.3    Security staff shall conduct visual welfare checks of inmates at staggered intervals not to exceed every 30 minutes.

1.3.1    Visual checks shall occur at random times within each 30-minute interval but no longer than 30 minutes shall pass between each random check. The intent is to make visual checks unpredictable.

1.3.2    Breathing and signs of life shall be clearly observed.

1.3.3    Security staff shall observe whether items in the inmate's possession match those authorized by mental health staff on the Mental Health Disposition form.

1.3.4    Visual checks shall be documented on the Observation Record.

1.4    Suicide Watch:

1.4.1    Suicide Watch, 10-Minute:

1.4.1.1    10-minute suicide watch is indicated when an inmate is not actively engaged in self-harm but is presenting significant suicide risk factors and signs of suicidal intent.

1.4.1.2    Security staff shall conduct visual welfare checks of inmates at staggered intervals not to exceed every 10 minutes.

1.4.1.2.1    Visual checks shall occur at random times within each 10 minute interval but no longer than 10 minutes shall pass between each random check. The intent is to make visual checks unpredictable.

1.4.1.2.2    Breathing and signs of life shall be clearly observed.

1.4.1.2.3    Security staff shall observe whether items in the inmate's possession match those authorized by mental health staff on the Mental Health Disposition form.

1.4.1.2.4    Visual checks shall be documented on the Observation Record.

1.4.2    Suicide Watch, Continuous:

1.4.2.1    Continuous suicide watch is indicated when an inmate is actively engaged in self-harm or considered by mental health staff to be at high imminent risk for suicide or self-harm and is presenting with significant suicide risk factors and signs of suicidal intent.

1.4.2.2    Continuous suicide watch is also indicated when:

1.4.2.2.1    The suicidal or mental health inmate cannot be immediately placed in a designated watch cell, e.g., the inmate is placed in a standard cell, holding cell or enclosure.

1.4.2.2.2    The placement area contains protrusions or tie-off points that could be used in a suicide attempt.

1.4.2.2.3    The inmate by necessity retains objects or items that could be used in a suicide attempt e.g., medical items/appliances, sanitary pads, additional clothing, etc.

1.4.2.2.4    The inmate is returning from the hospital after medical treatment for self-harm.

1.4.2.3    For continuous suicide watch, security staff shall observe the inmate on a continuous, uninterrupted basis and shall have a clear, unobstructed view of the inmate.

1.4.2.4    Security staff shall note "continuous visual observation" for continuous suicide watch on the Observation Record.

1.4.3    Mental health staff shall immediately complete a suicide risk assessment as defined in section 807.02 whenever an inmate is placed on 10-minute suicide watch or continuous suicide watch.

1.4.3.1    If an inmate is placed on 10-minute suicide watch or continuous suicide watch during non-business hours including nights and holidays, mental health staff shall complete a suicide risk assessment no later than the next working day.

1.4.4    Mental health staff shall evaluate the inmate every four hours while he/she is on 10-minute suicide watch or continuous suicide watch is in effect.

1.4.4.1    During non-business hours including nights and holidays, health staff shall evaluate the inmate on 10-minute suicide watch or continuous suicide watch every four hours.

1.5    Security staff conducting mental health or suicide watches shall notify mental health staff immediately through the shift commander of any significant changes in an inmate's behavior while on watch.

1.5.1    During non-business hours including nights and holidays, security staff shall immediately contact the Mental Health Urgent Responder through Control.

1.6    The shift commander shall tour the watch cell area once every four hours to ensure that Observation Records are complete, accurate, and posted along with Mental Health Disposition forms and those visual checks are being performed in staggered, random manner.

1.7    Security staff shall ensure that an inmate on mental health or suicide watch is provided the following health care necessities:

1.7.1    Toilet use, upon request.

1.7.2    Fluid intake, at least once per hour, while awake.

1.7.3    Regularly scheduled meals, including special medical and religious diets, of the same quantity and nutritional quality as meals served to the general population.

1.7.4    Paper sack lunches or food served on paper or shatter-resistant trays not requiring eating utensils may be provided to inmates on suicide watch, if necessary, but should be of the same quantity and nutritional quality as meals served to the general population.

1.7.4.1    Food served should be free of items that can be used for self-harm e.g., bones.

1.7.4.2    Paper trays, paper sacks, napkins, and all other extraneous items shall be removed after the inmate completes eating.

1.7.4.3    Cellophane shall be removed from food prior to serving the food to the inmate.

1.7.5    Prescribed medication, in unit dosage and by watch swallow.

1.8    When evaluating inmates on watch during normal waking hours, mental health and health care staff shall interact with and not just observe inmates.

1.9    Mental health and health care staff shall document their evaluations of inmates on watch as progress notes in the mental health section of the medical record.

1.9.1    In the first progress note after an inmate is placed on a watch, mental health staff shall document the circumstances that necessitated the watch and an assessment of the inmate’s current status.

1.10    Inmates on mental health or suicide watch shall not have their watch status downgraded or discontinued until mental health staff has assessed the inmate, thoroughly reviewed the inmate's medical and mental health record, any other relevant documentation, and conferred with security staff about the inmate’s observed behavior on watch.

1.11    Inmates on watch shall be downgraded from continuous suicide watch to 10-minute suicide watch to mental health watch, each for a reasonable and clinically appropriate period of time prior to complete discontinuation of watch.

1.11.1    Mental health inmates who are not suicidal and who have been placed on continuous suicide watch because they cannot be placed in a designated watch cell may be directly and completely discontinued from watch.

1.12    Each change in watch status i.e., mental health, 10-minute suicide watch, continuous suicide watch or conditions of watch, e.g., allowed items on watch, shall be documented on a new Mental Health Disposition form, with both copies of the previous Mental Health Disposition being lined out and signed, stamped, dated and timed by the mental health staff making the change.

1.12.1    Mental health staff shall document the rationale for the change in watch status or watch conditions in the mental health record as a progress note.

1.12.2    Mental health and the shift commander shall ensure that, when needed, a new Observation Record is initiated if there is a change in watch status.

1.13    When watch status is discontinued altogether, the current Mental Health Disposition form shall be modified as above with "Cancelled" noted on the form.

1.14    Only a psychiatrist or psychologist or other mental health staff in consultation with a psychiatrist or psychologist shall modify watch status, discontinue watch status, or make changes in the conditions of watch. Watch status or discontinuation of watch status shall occur only after an in-person evaluation of the inmate on watch.

1.15    Upon complete discontinuation of watch status, mental health staff shall prepare a discharge summary as a note-to-file documenting the following:

1.15.1    Initial reason for the watch.

1.15.2    Observed behavior during the period of watch.

1.15.3    Any evaluation, staffing, or consultation regarding the inmate on watch.

1.15.4    Therapeutic or other interventions.

 

1.15.5    Rationale for discontinuation of watch.

 

1.15.6    Specific communication with mental health and security staff on the unit receiving the inmate from watch, i.e., who was contacted, with a brief synopsis of the communication.

1.1    Suicide prevention aides shall be utilized in relatively high-risk areas (e.g., single-celled areas, lockdown units) to supplement staff observation and facilitate the Department's suicide prevention efforts.

1.2    Inmates applying for the position of suicide prevention aide shall be screened by security and mental health staff.

1.2.1    Suicide prevention aides shall be free of any mental health or custody issues that would impair or jeopardize their ability or willingness to supplement staff observation and facilitate inmate suicide prevention.

1.2.2    Suicide prevention aides shall be free of any significant mental health or custody issues that would adversely impact the safe, secure and orderly functioning of the institution.

1.3    Inmates selected and screened to become suicide prevention aides shall be trained by mental health staff in suicide prevention, general mental health issues, and active listening skills.

1.3.1    Quarterly refresher training and debriefing will be conducted by mental health staff with suicide prevention aides.

1.4    While working, suicide prevention aides will be responsible for reporting inmate behavior that may signal significant mental health issues or suicide risk to security staff, who in turn will contact mental health staff.

1.4.1    Suicide prevention aides will alert security staff to imminent or ongoing inmate suicide attempts.

1.4.2    Suicide prevention aides will walk around the area they are assigned to observing the inmate population for any indications of significant mental health issues, suicide risk, or imminent or ongoing inmate suicide attempts.

1.5    Recruitment, payment, and supervision of suicide prevention aides will be handled by Offender Operations staff in consultation with mental health staff.

1.1    Guiding Principles

1.1.1    Clinically ordered restraint may be authorized when an inmate exhibits serious self-injurious behavior as a result of a mental disorder. Serious self-injurious behavior is defined as behavior that endangers the inmate's life or significantly affects the inmate's physical health and wellbeing.

1.1.2    Clinically ordered restraint is a therapeutic intervention authorized by appropriate mental health staff to safely limit a mentally disordered inmate's mobility and to protect the physical wellbeing of the inmate.

1.1.3    Clinically ordered restraint shall only be used when all other less restrictive measures have failed.

 

1.1.4    Clinically ordered restraint shall never be used as a form of punishment.

 

1.1.5    Clinically ordered restraint shall be employed for the shortest time necessary.

1.1.6    Clinically ordered four-point non-ambulatory restraints shall be employed only in designated suicide-resistant watch cells equipped with authorized restraint beds or chairs. If there is a need to place the restrained inmate in an area other than a designated watch cell (e.g., a medical unit), the inmate shall be restrained in an authorized restraint chair. There shall be no improvising of restraint beds or chairs.

1.1.7    Clinically ordered restraint shall be done in a manner to minimize the risk of harm to the restrained inmate.

1.1.8    Inmates shall not be restrained in unnatural positions (e.g., hog-tied, facedown, or spread-eagled)

1.1.9    Soft restraint devices shall be used for clinically ordered restraint. Metal or other hard restraints shall not be used for clinically ordered restraint. Soft restraint devices shall not be used for security reasons.

1.1.10    Safety helmets shall be used in conjunction with clinically ordered restraints when the restrained inmate is in danger of harming him or herself through head banging or other head movements.

1.1.11    Mental health staff shall never participate in the restraint of inmates for non-mental health reasons.

1.1.12    All staff who applies clinically ordered restraints shall be trained in the proper application of restraints and must successfully complete annual refresher training in the application of clinically ordered restraints.

1.1.13    Facilities that do not employ clinically ordered restraint (non-corridor complexes) shall transfer inmates to facilities equipped to provide this intervention (corridor complexes, the Alhambra Behavioral Health Treatment Facility at ASPC-Phoenix). During transportation, inmates requiring clinically ordered restraints shall be placed in ambulatory soft restraints.

1.1.14    Episodes of clinically ordered restraint shall be videotaped in their entirety.

1.2    Procedural Instructions for Staff

1.2.1    Upon notification by security staff or when clinically appropriate, a psychologist, psychiatric nurse practitioner, or psychiatrist shall assess the inmate to determine if clinically ordered restraint is required.

1.2.1.1    During non-business hours including holidays and nights, the urgent response psychologist, urgent response psychiatric nurse practitioner, or urgent response psychiatrist shall determine if clinically ordered restraint is required.

1.2.1.2    A Warden, Deputy Warden or Duty Officer may issue a temporary written order to restrain an inmate engaged in serious self-injurious behavior, obtaining written or verbal authorization from a psychologist or psychiatrist within one hour after restraint application.

1.2.1.3    The charge registered nurse will review the medical file to ensure that no medical condition exists that could place the inmate in danger due to a restraint configuration that could cause harm.

1.2.2    The psychologist or psychiatrist assessing the situation shall authorize clinically ordered restraint in progressive fashion, beginning with the least restrictive measures and progressing to more restrictive measures, until the mentally disordered inmate's self-injurious behavior is adequately controlled to prevent serious physical harm.

1.2.2.1    The progression in restraint application proceeds from no restraint (i.e., placement on a continuous suicide watch) to hand and/or leg restraints with or without safety helmet to four-point restraints in a designated restraint bed or chair.

1.2.2.1.1    Four-point restraints in a designated restraint bed or chair shall only be used in the event that the inmate is demonstrating self-injurious behavior that is life-threatening or likely to cause significant risk to the inmate's physical wellbeing.

1.2.2.1.2    The determination that self-injurious behavior is life-threatening or likely to cause significant risk to the inmate's physical wellbeing shall be made by the authorizing psychologist in consultation with medical staff or by an authorizing psychiatric nurse practitioner or psychiatrist.

1.2.2.2    During normal business hours, the psychologist, psychiatric nurse practitioner, or psychiatrist authorizing clinically ordered restraint shall increase or decrease the restrictiveness of the restraints based on direct assessment of the inmate. During non-business hours including nights and holidays, input from security, medical or other mental health staff on-site may be used instead of direct observation.

1.2.2.3    The psychologist, psychiatric nurse practitioner, or psychiatrist authorizing clinically ordered restraint shall apply the least restrictive intervention likely to adequately control the inmate and prevent serious physical harm.

1.2.2.4    The authorizing psychologist, psychiatric nurse practitioner, or psychiatrist shall order the following for restrained inmates on the Mental Health Disposition form (1103-44):

1.2.2.4.1    The inmate shall be placed on a continuous suicide watch during and subsequent to the application of clinically ordered restraint until the inmate is adequately and directly assessed by a psychologist, psychiatric nurse practitioner, or psychiatrist for risk of self-harm and suicide.

1.2.2.4.2    The authorization for clinically ordered restraint shall not exceed 12 hours from the time restraints are first applied.

1.2.2.4.3    While restrained the inmate shall be clothed to the fullest extent possible, but at a minimum with undergarments, safety smock or, if not practical, covered with a safety blanket.

1.2.2.4.4    The inmate shall be provided a suicide-resistant mattress and two safety blankets.

1.2.2.4.5    The inmate shall be examined and/or treated by medical staff within 15 minutes after the application of restraints and as medically indicated. Vital signs shall be taken at this time and documented in the medical record.

1.2.2.4.6    The inmate shall be checked once each hour by security or medical staff for swelling or other indications that the restraints are too tight and, if so, to loosen the restraints.

1.2.2.4.7    The charge registered nurse shall monitor vital signs and physiologically correct body positioning every two hours throughout the restraint episode.

1.2.2.4.8    The inmate shall be provided toilet use upon request.

1.2.2.4.9    The inmate shall be offered drinking water at a minimum of once each hour while awake.

1.2.2.4.10    The inmate shall be provided regularly scheduled meals, including special medical and religious diets, of the same quantity and nutritional quality as meals served to the general population.

1.2.2.4.10.1    Paper sack lunches or food served on paper or shatter-resistant trays not requiring eating utensils may be provided to inmates on suicide watch, if necessary, but should be of the same quantity and nutritional quality as meals served to the general population.

1.2.2.4.10.2    Food served should be free of items that can be used for self-harm e.g., bones.

1.2.2.4.10.3    Paper trays, paper sacks, napkins, and all other extraneous items shall be removed after the inmate completes eating.

1.2.2.4.10.4    Cellophane shall be removed from food prior to serving the food to the inmate.

1.2.2.4.10.5    When safety and security precautions dictate, only one hand shall be released for meals.

1.2.2.4.11    The inmate shall be given the opportunity to exercise each limb for at least ten minutes every two hours to prevent blood clots.

1.2.2.4.11.1    An inmate in non-ambulatory four-point restraints shall be released from restraint to the bed or chair and allowed to ambulate in four-point restraints after each two-hour interval for a ten minute period.

1.2.2.5    Once the restrained inmate stabilizes and ceases self-injurious behavior, the authorizing psychologist, psychiatric nurse practitioner, or psychiatrist shall decrease the restrictiveness of the restraints in graduated fashion.

1.2.2.6    In the event that the restraint episode is prolonged, the initial authorizing psychologist, psychiatric nurse practitioner, or psychiatrist assumes responsibility for briefing another psychologist, psychiatric nurse practitioner, or psychiatrist (including the urgent response psychologist, psychiatric nurse practitioner, or psychiatrist) of the clinical restraint situation prior to leaving his or her duty post. This briefed psychologist, psychiatric nurse practitioner, or psychiatrist then assumes the role of authorizing psychologist, psychiatric nurse practitioner, or psychiatrist.

1.2.2.7    In the event that clinically ordered restraint needs to be continued beyond 12 hours from initial application of restraints, the authorizing psychologist or psychiatrist shall consult with the Mental Health Program Manager or designee.

1.2.2.7.1    After consulting with the Mental Health Program Manager or designee, the authorization for clinically ordered restraint may be renewed for an additional 12 hours except in the case of four-point restraints in a restraint bed or chair.

1.2.2.7.2    When the inmate is restrained by four-point restraints in a restraint bed or chair, the Mental Health Program Manager shall direct that a face-to-face evaluation of the inmate be conducted by a psychologist, psychiatric nurse practitioner, or psychiatrist to determine the need for continued four-point restraints.

1.2.2.7.3    The Mental Health Program Manager or designee shall arrange for transfer to a licensed mental health facility as soon as feasible in the event that four-point restraints continue to be needed beyond a 24-hour interval.

1.2.2.8    In the event that methods of restraint have been inadequate to prevent serious acts of self-harm, the Mental Health Program Manager or designee shall consult with a psychiatric nurse practitioner or psychiatrist regarding emergency psychotropic medication.

1.2.2.9    A psychiatric nurse practitioner or psychiatrist may order emergency psychotropic medication for and administer it involuntarily to an inmate with a mental disorder if, after evaluating the severity of the inmate's symptoms and the likely effects of the particular drug to be used, the psychiatrist determines that:

1.2.2.9.1    An emergency exists.

1.2.2.9.2    Alternative methods of restraint are inadequate to prevent serious self-harm.

1.2.2.9.3    Forced medication is required, as a last resort, to address the emergency and to minimize the likelihood of serious self-harm.

1.2.3    Mental health and medical staff involved in clinically ordered restraint episodes shall document in the medical record all assessments or other relevant information.

1.2.3.1    The charge registered nurse shall document restraint assessments every two hours.

1.2.4    The Deputy Warden shall ensure that the shift commander makes any necessary notifications in accordance with Department Order #105, Information Reporting System, and completes and distributes a Use of Force/Incident Management Report, Form 804-2 and a Significant Incident Report (SIR), Form 105-3 as appropriate.

1.3    Review

1.3.1    Within five working days of a clinically ordered restraint episode involving non-ambulatory restraints, complex operations, health and mental health staff shall review pertinent documentation and audiovisual recordings to evaluate compliance with policy guidelines. By the fifth working day, a report of this review shall be forwarded to the Mental Health Program Manager, the Counseling and Treatment Services Quality Assurance Manager, and a designated Offender Operations staff.

807.08    MENTAL HEALTH FOLLOW-UP AFTER WATCH

1.1    All inmates who have been discharged after a downgraded suicide watch shall be seen by mental health staff on three separate days during the first work week following discharge, once per work week for two months, and then as clinically indicated and according to their designated mental health need level.

1.2    All inmates who have been discharged after only a mental health watch shall be seen by mental health staff once per week for four weeks and then as clinically indicated and according to their designated mental health need level.

807.09    INTERVENTION

1.1    It is the standard of the Department to assess and render aid to all medical emergencies, including suicide attempts, within three minutes of becoming aware of a non-responsive inmate or an inmate in medical crisis.

1.2    Wardens shall ensure that Post Orders and Institution Orders incorporate the three minute emergency response standard.

1.3    In the event that an inmate is found non-responsive, in a state of medical emergency, or in the act of attempting suicide, staff shall assess the situation and render in-cell aid within three minutes of becoming aware of the situation.

1.4    In the instance where an inmate is secured in a two-person cell, a minimum of two staff (including non-security staff) may access the cell to respond and initiate aid. Where an inmate is in a single cell, one staff member shall access the cell to respond and initiate aid. Assembling a team to remove an inmate from a cell is not required. Having a supervisor present prior to cell access or before initiating aid to an inmate is not required.

1.5    For all emergency responses, staff shall assess the situation and proceed as follows within the three minute time frame:

1.5.1    Activate Incident Management System (IMS). Inherent in the IMS is the notification to supervisory staff and medical responders as required.

1.5.2    In the case of a non-responsive inmate, issue two loud orders for inmate response.

1.5.3    Conduct a visual sweep of the area to determine that no weapons are present or accessible. If an inmate's hands cannot be seen and he/she is non-responsive, an immediate judgment must be made by a first responder to determine whether the inmate's condition outweighs the potential risk involved in entering the cell/living area.

 

1.5.4    Remove other inmates from the cell/living area.

 

1.5.5    Videotape the entry whenever possible. However, the availability or arrival of a video camera may never delay entry into a cell/living area or the initiation of aid to an inmate.

1.6    Following discovery of a hanging attempt, staff shall proceed as follows:

1.6.1    Movement of the inmate should be minimized.

1.6.2    One staff member shall continuously lift the inmate until a second staff member cuts or removes the noose.

1.6.3    Staff should assume a neck/spinal cord injury and carefully place the inmate on the floor.

1.6.4    The inmate shall not be placed on a gurney or bunk. The inmate should remain on the floor.

1.6.5    Should the inmate lack vital signs, CPR shall be initiated immediately and continued by security or other staff until relieved by health staff.

1.7    Following an attempt by cutting and the initiation of IMS, staff shall proceed as follows:

1.7.1    Immediately remove the cutting instrument from the area.

1.7.2    Stop the bleeding by applying direct pressure over the wound with sterile dressing or clean cloth.

1.7.3    Elevate the injured body part if feasible.

1.7.4    Use universal precautions in all first aid and life-saving measures.

1.8    Upon discovery of an inmate who is non-responsive, staff shall never presume that the inmate is dead and instead shall implement life-saving measures.

1.1    In the event of a suicide, all appropriate officials shall be notified in accordance with Department Order #105, Information Reporting System.

1.2    Following a suicide, the deceased inmate’s family shall be notified in accordance with Department Order #711, Inmate Death or Hospitalization Notification, as well as appropriate outside authorities.

1.3    Following a suicide, the deceased inmate's crime victim(s) shall be notified as to the inmate's death per Department Order #1001, Inmate Release System.

1.4    All staff who responded to the inmate suicide, including security, health and mental health staff, shall submit Information Reports that include their knowledge of the inmate and the incident.

807.11    POST-SUICIDE DEBRIEFING AND MULTIDISCIPLINARY REVIEW

1.1    Debriefing of all affected inmates shall be offered by mental health staff following an inmate suicide.

1.2    Staff shall be provided debriefing from the Critical Incident Response Team (CIRT).

1.3    A multidisciplinary review shall be conducted.

1.3.1    The review for all inmate suicides will include:

1.3.1.1    An inquiry regarding circumstances surrounding the suicide.

1.3.1.2    Relevant training of involved staff.

1.3.1.3    Pertinent medical and mental health information regarding the deceased inmate.

1.3.1.4    Possible precipitating factors leading to the suicide.

 

1.3.1.5    Recommendations for improvements in policy, training, physical plant; medical or mental health services; and operational procedures.

1.3.2    The review will be conducted in addition to any mortality review completed by medical staff.

1.4    Findings of the multidisciplinary review shall be forwarded to the Quality Assurance Committee.

CLINICALLY ORDERED RESTRAINT - A therapeutic intervention authorized by a psychologist, psychiatric nurse practitioner, or psychiatrist to safely limit a mentally disordered inmate's mobility and to protect the physical wellbeing of the inmate. Clinically ordered restraint may be authorized when an inmate exhibits serious self-injurious behavior as a result of a mental disorder.

HISTORICAL INFORMATION - In the context of this Department Order, this refers to information about prior self-harm or suicide attempts, whether in the recent or distant past.

IMMINENT RISK OF SELF-HARM OR SUICIDE - A situation where the inmate may not be currently and actively harming him or herself or attempting suicide but is very likely to do so in the immediate future is one where there is imminent risk of self-harm or suicide.

___________________________
Dora Schriro
Director

Attachment A, ADC Suicide Warning Signs Card

1101-16, Observation Record

1103-27, Mental Health Assessment

1103-44, Mental Health Disposition