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DEPARTMENT OF CORRECTIONS

 

DIVISION 76

SUICIDE PREVENTION IN CORRECTIONAL FACILITIES 

291-076-0010

Authority, Purpose and Policy

(1) Authority: The authority for this rule is granted to the Director of the Department of Corrections in accordance with ORS 179.040, 423.020, 423.030, and 423.075.

(2) Purpose: The purpose of this rule is to prevent suicides among the inmate population.

(3) Policy: It is the policy of the Department of Corrections to provide immediate assistance whenever an inmate demonstrates, or is reported to be at risk of self-destructive behavior.

Stat. Auth.: ORS 179.040, ORS 423.020, ORS 423.030 & ORS 423,075
Stats. Implemented: ORS 179.040, ORS 423.020, ORS 423.030 & ORS 423.075
Hist.: CD 4-1997, f. & cert. ef. 2-12-97

291-076-0020

Definitions

(1) Behavioral Health Services (BHS): A unit of ODOC Health Services with primary responsibility for the assessment and treatment of inmates with mental illness and developmental disabilities.

(2) Mental Health Provider: Any person employed by the Department or engaged by contract with the Department for the explicit purpose of providing mental health services.

(3) Suicide Assessment: A brief but formal assessment of mental status conducted by a mental health provider or a registered nurse in consultation with a mental health provider, concluding with a judged level of suicidal risk.

(4) Suicide Attempt: Any self-injury requiring significant medical intervention as determined by a mental health provider

(5) Suicide Close Observation: In moderate risk situations, unobstructed visual observation of the inmate is required at staggered intervals, not to exceed 15 minutes, with recorded observation within each 15 minute interval.

(6) Suicide Warning Signs: The following list provides some of the indicators of suicide potential:

(a) Talk of suicide, threats of suicide;

(b) Extreme sadness or crying;

(c) Apathy, loss of interest in all or almost all people and activities;

(d) Loss of appetite or weight;

(e) Walking or completing tasks at an unusually slow speed;

(f) Difficulty concentrating or thinking;

(g) Sleep disturbances;

(h) Emotional flatness; seems numb, non-reactive;

(i) Difficulty carrying out routine tasks; e.g., eating, dressing, etc.;

(j) Tension and agitation; inability to relax or sit still, pacing, hand wringing;

(k) Withdrawal, silent, uncommunicative;

(l) Pessimistic attitude about the future;

(m) Emotional outbursts, sudden expression of anger for no apparent reason; or

(n) Feeling of hopelessness and helplessness.

(7) Suicide Watch: In high risk situations, continuous and unobstructed one-to-one view of the inmate is required at all times with recorded observation within each 15-minute interval.

Stat. Auth.: ORS 179.040, 423.020, 423.030 & 423.075
Stats. Implemented: ORS 179.040, 423.020, 423.030 & 423.075
Hist.: CD 4-1997, f. & cert. ef. 2-12-97; DOC 23-2000, f. & cert. ef. 11-6-00; DOC 20-2008, f. & cert. ef. 8-14-08

291-076-0030

Procedures

(1) Identification: All new admissions to the Department of Corrections will receive a mental health screening interview as part of the intake process. The mental health screening will include mental health history, suicide potential, evidence of psychosis, or other acute mental health emergency.

(2) Training: All employees having direct inmate contact will receive suicide prevention training.

(a) Suicide warning signs, prevention strategies, and response procedures will be present in New Employee Orientation (NEO) and in annual in-service training.

(b) Suicide prevention training curriculum will be approved by the Administrator of Behavioral Health Services.

(c) Additional training is required of staff on special housing units where mentally ill or suicidal risk inmates are concentrated.

(3) Referral: Inmates with significant potential for self harm or who are displaying suicide warning signs should be referred to Behavioral Health Services for evaluation.

(4) Assessment: Any Department staff, upon concluding that sufficient suicide warning signs are present to merit concern, should immediately notify a registered nurse or mental health provider. A mental health provider or registered nurse in consultation with a mental health provider will determine if suicide risk is present.

(a) When an inmate is placed on suicide watch or suicide close observation, the inmate should be reassessed by a registered nurse every four hours and by a mental health provider within 24 hours, in person or by phone, and once every 24-hour period thereafter.

(b) At those facilities without 24-hour nursing coverage, a suicide assessment will be completed every four hours when nursing staff are on duty, as well as at the end of the last shift and the beginning of the next shift. During the interim, specific written instructions shall be given to the officer-in-charge regarding what actions should be taken if the inmate's mental status appears to deteriorate, or if any acts of self-destruction are carried out.

(c) All suicide assessment, reassessments, inmate responses, as well as any written instructions which are given to the officer-in-charge, will be documented in the inmate’s Health Services file.

(5) Monitoring — Suicide Watch (high risk): The officer-in-charge shall be responsible for placing an inmate on suicide watch based on the instruction from a mental health provider or registered nurse in consultation with a mental health provider. The officer-in-charge may initiate a suicide watch until a registered nurse or mental health provider arrives.

(a) An inmate on suicide watch shall be under continuous and unobstructed one-to-one observation at all times.

(b) When an inmate is placed on suicide watch, the officer-in-charge shall remove any items that pose a threat to self-harm from the inmate’s living area based on the instruction from a mental health provider or a registered nurse in consultation with a mental health provider.

(c) Any inmate placed on suicide watch will be continued in this status until a mental health provider, or a registered nurse in consultation with a mental health provider, determines that the suicide watch is no longer necessary, and has notified the officer-in-charge. The officer-in-charge will then order the suicide watch discontinued and property will be returned as instructed.

(d) If the mental health provider decides to maintain an inmate on suicide watch past 48 hours, the officer-in-charge will be notified and arrangements will be made for the transportation of the inmate to the nearest Mental Health Infirmary. It is the responsibility of the mental health provider to communicate to the Mental Health Infirmary receiving staff of the impending admission.

(6) Monitoring -- Suicide Close Observation (moderate risk): The officer-in-charge shall be responsible for placing an inmate on suicide close observation based on the instruction of a mental health provider or a registered nurse in consultation with a mental health provider. The officer-in-charge may initiate suicide close observation until a registered nurse or mental health provider arrives.

(a) Suicide close observation requires unobstructed one-to-one observation of the inmate at staggered intervals, not to exceed 15 minutes (e.g., 9:15, 9:25, 9:34, 9:49, 10:00).

(b) When an inmate is placed on suicide close observation, the officer-in-charge shall remove items that pose a threat to self-harm from the inmate’s living area based on the instruction from a mental health provider or a registered nurse in consultation with a mental health provider.

(c) Any inmate placed on close observation will be continued in this status until a mental health provider, or a registered nurse in consultation with a mental health provider, determines that the suicide close observation is no longer necessary and has notified the officer-in-charge. The officer-in-charge will then order the suicide close observation discontinued and property will be returned according to instruction.

(7) Housing: Inmates on suicide watch or suicide close observation may be housed in a segregation cell or special housing, or other cell modified and identified for use in suicide prevention if there is a visual and unobstructed view of the inmate so that he or she can be observed one-to-one on a continuous or staggered interval basis as required and property can be restricted as instructed.

(a) A mental health provider should be consulted as to the most appropriate housing. Upon determination and instruction by a mental health provider or a registered nurse in consultation with a mental health provider that an inmate cannot be safely maintained at a facility while on suicide watch or suicide close observation (in particular, those facilities without 24-hour nursing coverage), arrangements will be made to transfer the inmate to an appropriate facility for observation and intervention.

(b) The mental health provider or registered nurse in consultation with a mental health provider will communicate the details of the case to a mental health provider and registered nurse at the receiving facility before the inmate arrives at the receiving facility.

(8) Communication: Throughout the process of suicide risk assessment and intervention, Department staff and mental health providers will work closely together to ensure adequate and effective communication.

(9) Intervention: If a staff member discovers a suicide in progress, the following steps will be followed using universal blood and body fluid precautions:

(a) Call for assistance.

(b) If it is a hanging, the staff member shall cut the inmate down immediately.

(c) Emergency first aid procedures should be followed in the event of any self-destructive behavior and should be continued until Medical Services staff arrive and give further instructions.

(d) First aid procedures will be continued until relieved by Medical Services staff regardless of belief that the inmate is no longer alive.

(10) Notification and Reporting: The officer-in-charge will be responsible for initiating the facility’s notification process of any attempted suicide. The notification will include the local Behavioral Health Services Manager or designee and the on-call prescriber for that facility where the attempted suicide took place. In the event of a completed suicide, the notification will include the local Behavioral Health Services Manager or designee and the Behavioral Health Services Administrator or designee.

(11) The Department of Corrections rules on Death (Inmate) (OAR 291-027) and Emergency Preparedness (OAR 291-053) will be followed in the event of a completed suicide.

Stat. Auth.: ORS 179.040, 423.020, 423.030 & 423.075
Stats. Implemented: ORS 179.040, 423.020, 423.030 & 423.075
Hist.: CD 4-1997, f. & cert. ef. 2-12-97; DOC 23-2000, f. & cert. ef. 11-6-00; DOC 20-2008, f. & cert. ef. 8-14-08

291-076-0040

Review

(1) Suicide Review: If a suicide occurs, a formal suicide review will be completed as assigned by the Inspector General, including a review of the inmate’s Health Services files, related materials, and interviews of staff.

(a) The actual review of the Health Services files, related materials, and interviews of staff will be conducted by a multi-disciplinary team comprised of an assigned Special Investigations Unit manager, Assistant Superintendent of Security, Medical Services manager and Behavioral Health Services manager from a facility other than the facility where the suicide occurred.

(b) The Inspector General will appoint the chair of the team.

(c) The team will write a review and submit it to the Inspector General.

(d) The Inspector General will submit the review to the Director, Deputy Director, Assistant Director for Operations, Health Services Administrator, Behavioral Health Services Administrator, and the functional unit manager where the suicide occurred.

(2) Attempted Suicide Review: The Director, Deputy Director, Inspector General, Health Services Administrator, Assistant Director for Operations or Behavioral Health Services Administrator may request a formal review from a multi-disciplinary team as described in (1) above for any suicide attempt.

Stat. Auth.: ORS 179.040, 423.020, 423.030 & 423.075
Stats. Implemented: ORS 179.040, 423.020, 423.030 & 423.075
Hist.: DOC 20-2008, f. & cert. ef. 8-14-08

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