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Home My WebLink AboutSuicide Risk Management and InterventionIdaho Department of Correction Standard Operating Procedure Title: Suicide Risk Management and Intervention Page: 1 of 19 Control Number: 315.02.01.001 Version: 7.0 Adopted: 04/26/2005 IDOC Data Sensitivity Classification - L3 Restricted Chad Page, chief of the Division of Prisons, and Wally Campbell, chief psychologist, approved this document on 08/10/2020. Open to the public: Yes SCOPE This standard operating procedure applies to all Idaho Department of Correction employees, and residents in all IDOC and IDOC-contracted correctional facilities. Revision Summary Revision date (08/10/2020) version 7.0: Revised to include information about the Idaho Suicide Prevention Hotline and the Suicide Call Hotline Checklist. TABLE OF CONTENTS Board of Correction IDAPA Rule Number .............................................................................. 2 Policy Control Number 315 ................................................................................................... 2 Purpose ................................................................................................................................ 2 Responsibility ....................................................................................................................... 2 Standard Procedures ............................................................................................................ 3 1. Suicide Risk Prevention Overview ................................................................................ 3 2. Facility Mental Health Intake Procedure ....................................................................... 3 3. Idaho Suicide Prevention Hotline (ISPH) ...................................................................... 4 4. Monitoring Methods ...................................................................................................... 4 5. Suicide Risk Protocols .................................................................................................. 7 6. Emergency Procedures (Field Memorandum Required) ............................................... 9 7. Responding to a Suicide Attempt ............................................................................... 10 8. Physical Structure Requirements (Field Memorandum Required) .............................. 11 9. Mental Health Interactions .......................................................................................... 12 10. Transport of Residents on Suicide Monitoring ............................................................ 12 11. Conditions of Monitoring ............................................................................................. 13 12. Monitoring Documentation .......................................................................................... 14 13. Specialized Housing Units .......................................................................................... 14 14. Emergency Transfers ................................................................................................. 15 Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 2 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted 15. Companion Program (Field Memorandum Required) ................................................. 15 16. Suicide Resulting in Death ......................................................................................... 16 17. Psychological Autopsy Procedures ............................................................................ 16 18. Administrative Review ............................................................................................... 16 19. Critical Incident Stress Debriefing .............................................................................. 17 20. Program Review and Assessment ............................................................................. 17 21. Suicide Risk Management Training ............................................................................ 17 Definitions........................................................................................................................... 18 References ......................................................................................................................... 18 BOARD OF CORRECTION IDAPA RULE NUMBER None POLICY CONTROL NUMBER 315 Suicide Risk Management PURPOSE The prevention of suicide is a critical issue in all Idaho Department of Correction (IDOC) facilities. The purpose of this standard operating procedure (SOP) is to establish comprehensive guidelines for the identification and management of potentially suicidal residents in IDOC custody. RESPONSIBILITY The division of prisons chief or designee, in collaboration with the IDOC chief psychologist, is responsible to approve all facility field memorandums associated with this policy. Facility Heads Facility heads are responsible for: • Implementing and practicing the provisions of this SOP • Establishing safe areas to be used for suicide monitoring • Ensuring that all correctional officers, and other staff the facility head deems necessary, receive and maintain CPR certification • Ensuring that all staff members are trained annually in accordance with this SOP and that the training is documented • Reviewing and establishing or modifying post orders for conducting a suicide watch • Establishing a field memorandum as specified in this SOP Clinical Supervisors Clinical supervisors are responsible for: Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 3 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted • Determining who the on-site mental health professionals (MHPs) are at each facility. • Overseeing the treatment of suicidal individuals at their assigned facility. • Ensuring that the facility’s Suicide Risk Management Program conforms to the guidelines outlined in this SOP and the National Commission for Correctional Health Care (NCCHC). • Ensuring that during times of the clinical supervisor’s absence, such as vacation, training, or travel, that duties are transferred to another clinical supervisor and that facility staff is notified in writing regarding the transfer of duties. • The clinical supervisor is responsible for ensuring that MHPs are available (on site or on call) daily based on facility need and for communicating to the shift commander who is available at the facility to address mental health concerns. • Functioning as the facility suicide risk management coordinator (SRMC). STANDARD PROCEDURES 1. Suicide Risk Prevention Overview All staff members, whether security, programs, education, mental health, or medical, can observe warning signs of potential suicide (see Suicide Risk Factors). All threats, ideation, or other signs of potential suicide must be taken seriously; even if information is provided by another resident. Suicide management is a collaborative and cooperative effort between security, administrative, and mental health staff. All staff members are responsible to implement the procedures in the SOP when observations, behaviors, or verbalizations signal an indication that a potential suicide risk is present. At the first sign of suicide potential, staff must immediately implement the suicide risk management process by placing the resident under direct staff observation until a nurse or MHP assesses them. The mental health professional (MHP) is the authority for clinical decisions and actions regarding mental health care and suicide management. Once a resident has been placed on suicide watch, only an MHP, in coordination with the shift commander, is authorized to change the status of, release, or give additional property to a resident on a suicide-risk management plan. 2. Facility Mental Health Intake Procedure Suicide risk management begins with appropriate suicide risk and mental health screening. All residents must be screened upon arriving at an IDOC facility to include those arriving at a reception and diagnostic unit (RDU) or those transferring from another IDOC facility, county jail, contract facility, hospital, court, etc. The mental health screening procedure also applies to residents entering restrictive housing status or protective custody. The mental health screening process utilizes the Mental Health Screening form and is completed immediately upon arrival at an IDOC facility or prior to placement in restrictive housing. Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 4 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted Functional Roles and Responsibilities Step Tasks Security Staff 1 Place incoming residents where they are under constant staff supervision. Nursing Staff 2 • Interview each resident and complete the Mental Health Screening form as soon as possible or before placement in any housing assignment. • If the disposition on the medical screening indicates that there is no imminent suicide risk, forward the Mental Health Screening form to the MHP to be reviewed. • If suicide risk is indicated in the disposition on the screening, ensure the resident is under constant direct staff observation by security staff, immediately notify the shift commander, and implement the steps in section 3. Mental Health Professional 3 When no imminent suicide risk is noted, review the Mental Health Screening form within 24 hours and follow up as indicated. Submit the Mental Health Screening form to the medical provider for filing in the resident’s medical file. 3. Idaho Suicide Prevention Hotline (ISPH) IDOC provides its residents suicide prevention support through a Memorandum of Understanding (MOU) with Idaho Suicide Prevention Hotline (ISPH). The ISPH telephone number must be posted next to all telephones used by residents; the call is free of charge. This telephone service is available to residents during normal hours when telephone services are available according to each facility’s procedures. ISPH staff members are trained to forward information to IDOC security staff if they receive a call that requires emergency intervention of a follow-up visit. When the information is received, IDOC staff must immediately complete all applicable steps of the Suicide Hotline Call checklist. 4. Monitoring Methods Suicide monitoring consists of acute suicide watch, non-acute suicide watch, and close observation. These monitoring methods are used to ensure that a resident is safe during critical, high-risk periods and to provide an opportunity for them to stabilize. Acute Suicide Watch: Acute suicide watch is designed for actively suicidal residents who have engaged in self- injurious behavior or threaten suicide with a specific plan. Such individuals have generally required medical intervention because of their behavior. Acute suicide watch is the default suicide monitoring status until an MHP or (when an MHP is unavailable on nights, weekends, or holidays) a nurse, registered nurse (RN) or licensed practical nurse (LPN) Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 5 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted only, is available to assess the resident, which must happen as soon as possible. If there is not an MHP, RN or LPN at the facility, the resident must be placed on acute suicide watch until assessed by a clinician. During acute suicide watch, staff members must maintain constant, direct observation of the acutely suicidal resident at all times. Watch companions are never to be used for acute suicide watch monitoring. Staff may monitor more than one acutely suicidal resident at a time if they are housed in the same suicide monitoring cell. Facilities must identify suicide- monitoring cells capable of housing more than one resident in the facility FM related to this policy. The staff member should be standing or seated on a chair that is high enough to allow for line of sight observation through the cell window. This chair must be immediately outside of the monitoring cell with an unobstructed and constant view into the cell. Staff must maintain direct, line of sight supervision of residents on acute suicide watch and must never read or do any other activity that would take away from the ability to constantly monitor the resident on a watch status. Staff must document when the shift begins and ends or the watch is changed to a non- acute watch conducted by a watch companion, with the staff member’s name and associate number on the behavior observation log. Staff must document the behavior of a resident on acute suicide watch every 15 minutes or more frequently when the following activities occur: • Accessing or offered shower • Accessing dental hygiene items • Accessing to a toilet • Washing or sanitizing hands • Accessing drinking water • Consuming meals, including washing or sanitizing hands before meals • Any odd, bizarre or concerning behavior • Any attempts at self-injury or harm • Any threats of harm to self or others Acute suicide watch may only be conducted in a room designed for the purpose of suicide monitoring. Acute suicide watch must be outlined in the post orders of the units with suicide monitoring rooms. Only department-approved safety smocks and safety sleeping bags may be used while a resident is on acute suicide watch. Non-Acute Suicide Watch: Non-acute suicide watch is designed for potentially or inactively suicidal residents who express current suicidal ideation without a specific threat or plan and/or have a recent prior history of self-destructive behavior. Residents who deny suicidal ideation or do not threaten suicide but demonstrate other concerning behavior indicating the potential for self-injury should be placed on non-acute suicide watch. Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 6 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted During non-acute suicide watch, staff members are responsible for oversight of the monitoring, and must visually observe the resident at staggered intervals not to exceed fifteen minutes. Watch companions are residents who are trained to assist with supplementing the monitoring of other individuals who are on suicide watch under the supervision and direction of staff. Watch companions cannot be assigned to non-acute suicide watch without staff to provide monitoring and supervision. Watch companions must also have the ability to obtain rapid staff assistance. Watch companions must receive approved training on suicide risk management before being assigned suicide-monitoring duties. Non-acute suicide watch may only be conducted in a room designed for the purpose of suicide monitoring. Non-acute suicide watch must be outlined in the post orders of the units with suicide monitoring rooms. Only department- approved safety smocks and safety sleeping bags may be used while a resident is on non- acute suicide watch. Non-acute suicide watch may only be implemented by an MHP. Only if an MHP is unavailable during nights, weekends or holidays, a nurse, RN or LPN only, may implement non-acute suicide watch. Close Observation: Close observation is designed to be used for residents with increased psychotic or mental health symptoms that require placement in a holding cell for stabilization or to decrease stimuli. Close observation may be used as part of a risk management plan, in which a resident is given increased property and privileges while still being closely monitored by staff. Close observation may also be used as an option for a homicidal resident who is also mentally ill and displays an increase in mental health symptoms and verbal threats. During close observation, staff members are responsible for oversight of the monitoring, and must visually observe the resident at staggered intervals not to exceed fifteen minutes. Watch companions under the supervision and direction of staff may supplement staff monitoring. Watch companions cannot be assigned to close observation without staff to provide monitoring and supervision. Watch companions must also have the ability to obtain rapid staff assistance. Staff members and watch companions must receive approved training on suicide risk management before being assigned close observation monitoring duties. Close observation may be conducted in a room designed for the purpose of suicide monitoring or close observation. Close observation may only be implemented by an MHP. Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 7 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted 5. Suicide Risk Protocols Functional Roles and Responsibilities Step Tasks Staff Member 1 Immediately place resident under direct staff observation and contact the shift commander or assistant shift commander. Shift Commander 2 Ensure a staff member provides constant visual observation of the resident until the MHP or nurse arrives 3 Contact the on-site MHP or nurse. • During regular business hours, contact the MHP to assess the resident. • After hours, during weekends, or on holidays, contact the nurse, RN or LPN only, to assess the resident. • If there is no MHP, RN or LPN on site, place the resident on acute suicide watch and initiate a Default Acute Suicide Watch Order. MHP or Nurse (RN or LPN only) 4 • Assess the resident using the Suicide Watch Disposition for nursing staff or the Suicide Risk Assessment for MHPs within 30 minutes of the shift commander’s notification. • Notify the shift commander of the resident’s disposition. • For MHPs only, complete an Information Report documenting the resident as being placed on a monitoring status and complete a Suicide Watch/Close Observation Order. • For nurses, complete an Information Report documenting the resident as being placed on a monitoring status Shift Commander 5 Ensure that the resident is placed in a safe and secure location designed for suicide monitoring. Ensure staff conducts an unclothed body search and provide the resident with an approved sleep system or suicide resistant blanket, and a suicide smock. Shift Commander 6 Initiate the applicable Suicide Watch Order completed by the MHP or Default Acute Suicide Watch Order or Default Non-Acute Suicide Watch Order based on the assessment Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 8 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted Functional Roles and Responsibilities Step Tasks by the nurse. The default operational order cannot be altered until reviewed by an MHP. Complete and send a 105 Incident Report upon initial placement on a monitoring status and each time thereafter that the status changes. Assigned Security Staff 7 Review the Default Suicide Watch Order. • Acute suicide watch- maintain constant, direct line of sight monitoring of the acutely suicidal resident at all times. o Note your name and associate number on the Behavior Observation Log (Staff) at the beginning of the watch, when the watch is changed to a non-acute suicide watch, or close observation, or if the watch ends. • Document behavior every 15 minutes and when staff members visit at the time it occurs. Non-acute suicide watch- visually observe the resident at staggered intervals not to exceed fifteen minutes and document using a Behavior Observation Log (Staff) • Supervise watch companions and ensure they have the ability to obtain rapid staff assistance. Mental Health Professional 8 • If the resident was initially assessed by a nurse, within 2 hours of MHP arrival at the facility the next day, or by 0900, interview them and complete a Suicide Risk Assessment (SRA). On-call clinicians are required to see a resident placed on acute suicide watch by 0900 the following day if they were placed on acute suicide watch overnight. • If indicated, complete a new 105 Information Report and Suicide Watch/Close Observation Order citing specific suicide monitoring instructions and allowable property to replace the Default Suicide Watch Order. • When it is appropriate and safe to do so, develop and implement a step-down plan. Shift Commander 9 • Review, sign, and implement the Suicide Watch/Close Observation Order. If changes are recommended, those changes must be made in collaboration with the MHP. Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 9 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted Functional Roles and Responsibilities Step Tasks • Ensure the Suicide Watch/Close Observation Order is posted near the suicide watch room. Mental Health Professional 10 • See the resident on a suicide monitoring status daily and document the visit in a clinical contact note by the end of the shift and file in their medical file. • If reducing the suicide monitoring status from acute suicide watch to non-acute suicide watch or non-acute suicide watch to close observation: • Complete an SRA by the end of the shift and file in the resident’s medical file. • Save an electronic copy of the SRA in the mental health drive. • Complete a new Suicide Watch/Close Observation Order if applicable. Complete an Information Report and submit to the shift commander • If discontinuing the suicide monitoring status: • Complete an SRA by the end of the shift and file in the resident’s medical file. • Save an electronic copy of the SRA in the mental health drive. • Complete an Information Report and submit to the shift commander • After release from any suicide monitoring status, an MHP must see the resident daily for three days following the release. Document the visit in a clinical contact note by the end of the shift and file in the resident’s medical file. 6. Emergency Procedures (Field Memorandum Required) Cut-down Tools All IDOC facilities must have a cut-down tool on every unit that the facility head has approved. Cut down tools must be safe to use in a correctional environment. The tool must be immediately deployable on a routine basis to any location on the unit. A staff member may carry the tool, or it can be secured on the unit. In high-risk units, such as restrictive housing or mental health units, uniformed staff members must carry the tool on their duty belt. Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 10 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted Each facility must specify in its field memorandum the number of tools in the facility, where the tools are located, and the methods of securing the tools. Checking for Vital Signs Vital signs can be difficult to detect in emergencies; therefore, staff members who discover a resident during a suicide attempt should not presume they are dead, even if no vital signs are detected. Responding staff should always initiate and continue appropriate life-saving measures (CPR) until relieved by on scene medical staff or paramedics. Once CPR is initiated, only a physician, physician’s assistant or nurse practitioner is qualified to pronounce death or stop the lifesaving efforts. Paramedics may also terminate life-saving measures per their protocol. 7. Responding to a Suicide Attempt Protecting the crime scene is important, but the resident’s life, and rescue attempts to save their life, are the most important. Life-saving efforts must never be limited in an effort to preserve the crime scene. Functional Roles and Responsibilities Step Tasks Staff Member 1 Immediately implement the Incident Command System and request emergency medical assistance from facility medical staff. Staff Member(s) 2 • Assess the environment to ensure the scene appears to be safe. If the scene is unsafe, implement measures to make the scene safe. • If the resident is hanging, immediately cut them down, taking precautions to prevent additional injury to them and taking precautions to protect yourself from their weight. • If possible, attempt to preserve the knot in hanging events; however, saving the resident’s life is most important. • If not a hanging, take other first aid action as called for in the emergency (for example, clear airway, control bleeding). • Place the resident on a hard surface to facilitate CPR efforts. • Immediately begin CPR, unless the resident is breathing. • Continue CPR or, if breathing, monitor their condition closely until medical staff arrives. • If they stop breathing, immediately begin CPR. Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 11 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted Functional Roles and Responsibilities Step Tasks Medical Staff 3 • Assess situation and take over life-saving efforts. • Notify the shift commander of the resident’s status. • If necessary, arrange their transport to the nearest medical facility for additional life saving measures. Shift Commander 4 Provide appropriate security for the resident. Preserve the area and any evidence as a crime scene (see 504.02.01.001, Investigations and Intelligence Program). 5 Contact local law enforcement and request an investigation. 6 Ensure all involved staff complete Incident Reports and complete an Incident Notification Report (105 Report). 8. Physical Structure Requirements (Field Memorandum Required) The facility head, with input from the chief psychologist, is responsible to designate all rooms/cells used for suicide watch in a field memorandum. Such rooms must provide the ability to observe, protect, and maintain adequate control of the resident while on acute suicide watch, non-acute suicide watch or close observation. Typically, the suicide monitoring room(s) is in the health services area. Suicide monitoring rooms are engineered or modified to reduce access to items that can potentially be used to inflict self-harm. Every effort must be made to remove or modify fixtures or architectural features that would facilitate quick or easy self-injury or permit easy attachment for a ligature. Only limited and secure furnishings are allowed. Each cell used for close observation and/or suicide watch must have the following: • A track or rod system affixed above each cell front • A curtain with a minimum of 12 inches clearance from the floor • The top of the curtain must be clear The curtain must be closed anytime a clinical encounter occurs. The curtain will remain open at all other times. The room(s) used for suicide monitoring must permit easy access, privacy, and unobstructed vision of the resident at all times. The following facilities must designate and maintain suicide-monitoring rooms, to include staffing to operate them. These facilities must also implement a watch companion program. • Idaho State Correctional Institution (ISCI) • South Idaho Correctional Institution (SICI) Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 12 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted • Idaho Correctional Institution-Orofino (ICIO) • Idaho Maximum Security Institution (IMSI) • Idaho State Correctional Center (ISCC) • Pocatello Women’s Correctional Center (PWCC) • South Boise Women’s Correctional Center (SBWCC) 9. Mental Health Interactions Suicide monitoring encounters with mental health staff must be held privately. Residents must be provided an opportunity to meet in a private location for a face-to-face assessment with mental health staff. If unit staff refuse to move a resident to a private location, the mental health staff must contact the shift commander immediately. However, there may be times when movement to a private location is unavailable or when a resident may refuse to be moved. The shift commander is responsible to make the decision regarding movement. When a private location is unavailable, clinicians will meet with the resident at cell front. Privacy measures must be used to include a curtain (see section on physical structure requirements) and a white noise generator (or comparable devices designed to maximize privacy). The mental health staff must document in suicide watch daily documentation the level of privacy offered for every encounter. If the encounter did not occur in a private location, the reason must be documented. 10. Transport of Residents on Suicide Monitoring Residents may be transferred to another facility with suicide monitoring rooms at the discretion of the facility head, or facility duty officer, in coordination with the SRMC. Residents on Close Observation or Non-Acute Suicide Watch must be transferred before those on Acute Suicide Wa tch. In the event of a transport, the dignity of the resident must be maintained and they must remain under constant staff observation at all times. A special transport must be initiated in which they are transported individually or with others under suicide monitoring to maintain close supervision and ensure privacy. Prior to the transfer, all clinical and nursing documentation must be up to date and complete, to include the applicable suicide watch order(s), Suicide Watch Disposition if indicated, Suicide Risk Assessment and clinical case note(s). Transport of residents on suicide monitoring must comply with requirements in 322.02.01.001, Transports: Medical, Court, Family Emergency, and State. The following facilities without designated suicide monitoring rooms must transport residents to a facility with designated suicide monitoring rooms: • North Idaho Correctional Institution (NICI) – Transport to ICIO • Correctional Alternative Placement Program (CAPP) – Transport to ISCI • St. Anthony Work Camp (SAWC) – Transport to nearest county jail facility until a transport to ISCI can be made • East Boise Community Reentry Center (EB-CRC) – Transport to SBWCC Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 13 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted • Treasure Valley – Community Reentry Center (TRCRC) – Transport to ISCI • Nampa Community Reentry Center (N-CRC) – Transport to ISCI • Idaho Falls Community Reentry Center (IF-CRC) – Transport to nearest county jail facility until a transport to ISCI can be made Residents transported to a county jail on suicide watch will fall under the county jail’s suicide watch and monitoring procedures. IDOC MHP’s will not assess or follow up with the resident while in a county jail. Residents temporarily housed in a county jail for suicide watch will be assessed and receive clinical follow up by an IDOC MHP upon arrival to an IDOC facility. Residents transferred to another facility on a watch or monitoring status will be seen and followed by the sending facility’s MHP. The sending facility’s MHP is responsible for providing follow up services and documentation for the resident that was transported to another facility while on watch to include completing the Suicide Risk Assessment(s), daily clinical contact and corresponding SOAP notes, Information Report(s) and Operational Order(s). 11. Conditions of Monitoring Living conditions that the resident experiences during a suicide intervention are important components to suicide prevention. They must be housed in a safe environment with basic hygiene supplies and meals. In addition, they may have daily living items that the MHP, in coordination with the shift commander, has approved and documented on the Suicide Watch/Close Observation Order. In the event that the clinician and shift commander disagree on items to be provided on the Suicide Watch/Close Observation Order, the corresponding default suicide watch order will be implemented. Staffing will then occur the next day between the SRMC and facility head to determine what items are to be provided. Residents on suicide watch or close observation must have access to the following unless the MHP, in consultation with shift commander, determines that one or more are a risk to safety or security: • Offered the opportunity to shower at least once every 72 hours with necessary hygiene items • Access to dental hygiene items twice daily • Regular access to a toilet • Opportunity to wash or sanitize hands • Access to water every two hours, which may include the use of a small paper cup • Items of clothing to allow modesty, which include suicide prevention smock and paper underwear • Dietary needs met and utensils as needed to consume meals and the opportunity to wash or sanitize hands before meals • Mattress and suicide resistant bedding The MHP is responsible for staffing a resident’s medical needs with a medical provider when determining whether to restrict medical equipment or aids. This must be documented in the Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 14 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted suicide risk assessment and by the medical provider in a provider note. The MHP, in coordination with the shift commander, may deny or restrict these necessities only under extreme circumstances in which the denial is necessary to preserve the safety of the resident. The MHP must provide documentation, including the reason for the denial or restriction, using the Suicide Watch/Close Observation Order and a clinical case note. Denials or restrictions must be approved by the facility head (or facility duty officer after hours) before implementation. 12. Monitoring Documentation All residents must have a suicide risk assessment completed within 24 hours upon initial placement on acute suicide watch, non-acute suicide watch, or close observation, when modified to another monitoring status, and when released from acute suicide watch, non-acute suicide watch or close observation. A clinician must see residents daily while on a monitoring status and daily for three days after release from a monitoring status. Each clinician’s visit must be documented on a clinical case note if a suicide risk assessment is not required. Each day the MHP must review the Conditions of Monitoring, the Suicide Watch/Close Observation Order, and the Companion Watch Sheet, and document the review in the Behavior Observation Log (Staff). Behavioral Observation Log (Staff) Staff must maintain a Behavior Observation Log form for each resident assigned to acute suicide watch, non-acute suicide watch, or close observation. Assigned staff members must document their observations of the resident every fifteen minutes or more frequently as indicated. Activities such as searches, behavioral observations, review of the issued suicide watch order, and other information that may indicate a mental health need or decompensation must be documented. At the conclusion of the monitoring, the Behavior Observation Log must be forwarded to medical records for inclusion in the resident’s medical file. 13. Specialized Housing Units Restrictive Housing Restrictive housing units are high risk for suicide attempts. Restrictive housing includes administrative segregation, disciplinary detention, transit, segregation pending investigation (SPI), pre-hearing segregation (PHS), residents under sentence of death, and residents placed on cell restriction. The MHP must make weekly rounds of restrictive housing units and document that contact on a clinical case note. Prior to conducting rounds, they are to consult with security and unit staff concerning any residents needing special attention or that staff is concerned about. The MHP must also review and initial the Conditions of Monitoring noting any variation in the resident’s routine or behavior that might indicate a change in mental status or a concern about their well-being. The MHP’s contact with the residents may be performed cell-side if it is sufficient to assess their well-being. In cases in which a change in mood, routine, or behavior is noted, or in which there is a recent mental health history, contact must occur out of cell. Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 15 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted 14. Emergency Transfers When an MHP determines that an emergency transfer of the resident is needed due to acute mental illness, need for a higher level of care in a mental health unit, or due to an inability to provide adequate security or supervision resources, the MHP contacts the shift commander and indicates that an emergency transfer is needed. The shift commander notifies the facility duty officer and if approved, contacts the shift commander at the receiving facility to initiate the transport. 15. Companion Program (Field Memorandum Required) The facility head of any IDOC facility may authorize the use of a program utilizing watch companions to supplement monitoring during non-acute suicide watch and close observation. In facilities with a watch companion program, a MHP or designee is responsible for the selection, training, assignment, performance, and removal of individual companions. The MHP must maintain an accurate and up to date list of approved watch companions in the facility. This list must be available to the shift commanders. Due to the sensitive nature of such assignments, the selection of watch companions requires considerable care. Watch companions must be selected based upon their ability to perform the job and their reputation within the facility. Watch companions should be mature, reliable, and credible with staff and residents. They must be able to protect the suicidal individual’s privacy from other residents while being accepted in the role by staff. Watch companions must complete training before being assigned to monitoring. A sufficient number of watch companions should be trained, and alternate candidates should always be available. MHPs or designees may remove any watch companion from the program at their discretion. Except under unusual circumstances, watch companions do not conduct monitoring longer than 4 hours during a 24-hour period. The shift commander must approve any extension and the extension must not be more than an additional four hours. Watch companions may not assist in monitoring for longer than 8 hours in a 24-hour period. Watch companions document their work hours using the Companion Time Sheet. If a watch companion observes a resident on watch engaging in any type of self-injurious behavior, he must immediately report the activity to a staff member. Each facility must identify, in a field memorandum, how trained watch companions make contact with staff during their monitoring duty. The watch companion performing monitoring must have access to a means to immediately summon help (staff constantly present on the tier within sight and sound distance, phone, radio, etc.). Companion Watch Sheet For residents on non-acute suicide watch or close observation, watch companions document their observations in a Companion Watch Sheet a minimum of every 5 minutes. The Companion Watch Sheet is forwarded to medical records for inclusion in the resident’s medical file once the monitoring has concluded. Training Watch Companions Watch companions must receive training approved by the chief psychologist and sign the Companion Agreement of Understanding and Expectations. The watch companion must successfully complete an initial four hour structured training prior to being assigned to Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 16 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted complete a monitoring shift. To remain active in the program, watch companions must receive an additional four hours of refresher training semi-annually. Watch companions must meet at least quarterly with the MHP or designee to review procedures, discuss issues, and supplement training. The MHP or designee must maintain a file containing: • A signed Companion Agreement of Understanding and Expectations to be maintained for 7 years • Documentation of attendance and topics discussed at training meetings • A l ists of residents trained and approved to serve as watch companions (this list must be available to shift commanders) After a resident has served as a watch companion for a non-acute suicide watch or close observation, the MHP or designee may debrief watch companion(s), individually or in groups, to discuss experiences and any recommendations for program changes. Supervision of Watch Companions Watch companions should be standing or seated on a high/tall chair at window height to allow for line of sight observation. This chair must be immediately outside of the monitoring cell with an unobstructed and constant view into the cell. Watch companions must maintain direct, line of sight supervision of residents on non-acute suicide watch or close observation and must never read, complete homework or do any other activity that would take away from their ability to constantly monitor the resident on a monitoring status. The exception is that watch companions are allowed listen to music, with one earbud only, in their ear. Staff supervising a watch companion are required to ensure that the watch companion follows this process. Staff are responsible for providing direction or removing a watch companion if there is a safety concern about their ability to monitor. Staff monitoring of watch companions must occur every 15 minutes and must be documented on the Behavioral Observation Log. 16. Suicide Resulting in Death If it is determined that a death has occurred, the procedures described in 312.02.01.001, Death of an Inmate, must be followed. 17. Psychological Autopsy Procedures In the event of a suicide resulting in death, the chief psychologist or designee must conduct a psychological autopsy within 30 days of the person’s death in accordance with NCCHC Standards, Section MH-A-10. 18. Administrative Review Within 72 hours of each suicide attempt resulting in death, the chief of the prisons division must establish a serious incident review (SIR) panel in accordance with SOP 105.02.01.001, Reporting and Investigation of Major Incidents, Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 17 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted 19. Critical Incident Stress Debriefing Staff: When staff members are exposed to traumatic events such as suicide, they should have an opportunity to receive appropriate assistance. The facility head or designee must initiate the critical incident stress management process in accordance with SOP 112 .01.01.002, Critical Incident Stress Management Team. Residents: Counseling must be offered to residents who may be experiencing emotional distress related to either their involvement in the incident or involvement with the deceased individual. In addition, in the days following the suicide, mental health staff should have an increased presence on the unit in which the suicide occurred to ensure the general well- being of the population and to assess for additional clinical intervention that may be needed. 20. Program Review and Assessment A continuing analysis of the suicide risk management program's operation is crucial to its long- term effectiveness. The clinical supervisor must ensure that each facility maintains a suicide risk management log (the chief psychologist provides the suicide risk management log) that contains information about each suicide watch, completed suicide, and clinical comments pertinent to the case. By the 5th calendar day of each month, the SRMC at each facility submits that facility’s suicide risk management log to the chief psychologist. The chief psychologist must compile an annual report in January of each calendar year and make it available to facility heads, clinical supervisors, and IDOC agency leadership. 21. Suicide Risk Management Training Staff members assigned to directly monitor acutely suicidal residents must review the post orders associated with that responsibility, read the Watch Companion Program Guide, complete training, and complete the Watch Companion Program Quiz before monitoring a resident on suicide watch. All staff members, to include contract staff, working in, or with access to, IDOC correctional facilities must receive, at a minimum, training twice a year in the identification and management of potentially suicidal residents. An MHP may deliver the training or an online course may be used. The chief psychologist must approve all suicide risk management training and lesson plans. Suicide risk management training must include: • Identifying suicidal indicators and risk factors • Typical profiles of residents who completed suicides • Communicating with suicidal residents • Requirements for conducting formal suicide watches • Policies and procedures for screening, assessment Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 18 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted • Intervention and response to medical emergencies • Specific procedures for referring potentially suicidal residents for appropriate assessment and monitoring. DEFINITIONS Chief Psychologist: The Idaho Department of Correction (IDOC) employee who is primarily responsible for overseeing or managing the IDOC’s mental health services Clinical Supervisor: An individual that has demonstrated the skills, training, and certification to oversee the clinical skills of program delivery staff. The tasks and functions of supervisor include (1) planning, directing, monitoring, and evaluating the work of others and (2) offering information and techniques to help improve the knowledge and skills of those being supervised (3) acting as the facility Suicide Risk Management Coordinator. Mental Health Professional (MHP): A staff member who has specialized training and skills in the nature and treatment of mental illness to include, but not limited to, psychologists, psychiatrists, licensed masters or clinical social workers, licensed marriage and family therapists and licensed clinical and professional counselors who, by virtue of their education, credentials, and experience, are permitted by law to evaluate and care for patient. National Commission on Correctional Health Care (NCCHC): provides specific standards for medical and mental health care for the delivery of quality services. Monitoring: IDOC uses three levels of monitoring for residents demonstrating potential suicide behavior or for those who pose a significant and imminent risk to self or others: Acute Suicide Watch, Non-Acute Suicide Watch and Close Observation. Sleep System/Suicide Resistant Blanket/ Suicide Smock: Tear -resistant bedding and clothing specifically designed to reduce the risk of self-injury. Direct Observation: Being in the same room as the resident or looking through the window of a cell and keeping constant, direct observation of the resident at all times. REFERENCES 105 Information Report Suicide Risk Factors Companion Agreement of Understanding and Expectations Behavior Observation Log (Staff) Companion Time Sheet Companion Watch Sheet Conditions of Monitoring Default Acute Suicide Watch Order Default Non-Acute Suicide Watch Order Watch Companion Program Guide Control Number: 315.02.01.001 Version: 7.0 Title: Suicide Risk Management and Intervention Page Number: 19 of 19 Idaho Department of Correction IDOC Data Sensitivity Classification - L3 Restricted Watch Companion Program Quiz Mental Health Screening form Suicide Risk Assessment Suicide Watch/Close Observation Order Suicide Watch Disposition Suicide Hotline Call Checklist SOP 105.02.01.001, Reporting and Investigation of Major Incidents SOP 112 .01.01.002, Critical Incident Stress Management Team. SOP 312.02.01.001, Death of an Inmate SOP 322.02.01.001, Transports: Medical, Court, Family Emergency, and State SOP 504.02.01.001, Investigations and Intelligence Program – End of Document –