SOP_NUMBER: 508.28
TITLE: Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior
REFERENCE_CODE: VG68-0001
DIVISION: Health Services Division (Mental Health)
TOPIC_AREA: 508 Policy - Mental Health Suicide Prevention/ACU/CSU/BTU
EFFECTIVE_DATE: 2019-08-12
WORD_COUNT: 3166
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/106290
URL: https://gps.press/sop-data/508.28/

SUMMARY:
This policy establishes procedures for identifying, assessing, and managing offenders who are potentially suicidal, self-injurious, or assaultive in Georgia Department of Corrections facilities. All GDC staff must refer offenders suspected of mental health crises to mental health professionals for evaluation and appropriate stabilization. The policy applies to all facilities housing GDC offenders, including county and private prisons, and requires completion of suicide risk assessments and implementation of evidence-based interventions based on assessed risk level.

KEY_TOPICS: suicide prevention, suicidal behavior, self-injurious behavior, self-harm, mental health crisis, suicide assessment, suicide risk assessment, suicide precautions, assaultive behavior, homicidal behavior, mental health referral, Acute Care Unit, Crisis Stabilization Unit, suicide resistant cell, mental health observation, offender safety

ATTACHMENTS:
  1. Certificate of Approval for Crisis Stabilization Unit (CSU), Acute Care Unit (ACU), and Observation Cells
     URL: https://gps.press/sop-data/508.28-att-1/
  2. Offender Critical Incident Notification Form
     URL: https://gps.press/sop-data/508.28-att-2/
  3. Observation Cell Log
     URL: https://gps.press/sop-data/508.28-att-3/
  4. Suicide/Self-Injurious/Assaultive Behavior Information Form
     URL: https://gps.press/sop-data/508.28-att-4/
  5. Observation Cell Notification (Form M68-01-05)
     URL: https://gps.press/sop-data/508.28-att-5/
  6. Cell Analysis Form (M68-01-10)
     URL: https://gps.press/sop-data/508.28-att-6/

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FULL TEXT:
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|GEORGIA DEPARTMENT OF CORRECTIONS<br>Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|
|**Policy Number:** 508.28|**Effective Date:** 8/12/2019|**Page Number:** 1 of 10|
|**Authority:** <br>Commissioner<br>|**Originating Division:** <br>Health Services Division<br>(Mental Health)|**Access Listing:**<br>Level I: All Access|


**I.** **Introduction and Summary:**







It is the policy of the Georgia Department of Corrections **(** GDC) that offenders who are
potentially suicidal, self-injurious, and/or homicidal will be identified and referred for
further evaluation and/or appropriate stabilization/management. When a mental health
crisis is suspected by staff, the offender will be evaluated at a GDC facility equipped
with a mental health unit capable of evaluating and treating an offender in crisis. This
policy is applicable at all facilities that house GDC offenders to include county and
private prisons.

**II.** **Authority:**

A. GDC Standard Operating Procedures (SOPs): 209.04, Use of Force and Restraint for

Offender Control; 209.05, Stripped Cells and Temporary Confiscation of Personal
Property; 507.04.10, Consultations and Procedures; 507.04.78, Pharmacy and
Therapeutics Committee; 508.03, Death Notification, Critical Incident Notification
and Investigation; 508.19, MH Referral & Triage; 508.25, Psychiatric
Hospitalization; 508.27, Time Out and Physical Restraint; 508.29, Suicide
Precautions; 508.30, Mental Health Acute Care Unit; and 508.31, MH Crisis
Stabilization Unit;


B. NCCHC Standards for Health Services in Prisons;


C. NCCHC Standards for Health Services in Juvenile Detention and Confinement

Facilities;


D. Prison Health Care: Guidelines for the Management of an Adequate Delivery

System: National Institute of Corrections;


E. Prison Suicide: An Overview and Guide to Prevention: National Institute of

Corrections; and


F. ACA Standard: 4-4373.

**III.   Definitions:**

A. **Suicidal Behavior**    - The act, apparent intention, or threat of voluntarily and

intentionally taking one's own life.


B. **Self-Injurious Behavior**    - Any act or expressed intent of self-injury for an

apparently non-lethal goal.


|GEORGIA DEPARTMENT OF CORRECTIONS<br>Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|
|**Policy Number:** 508.28|**Effective Date:** 8/12/2019|**Page Number:** 2 of 10|
|**Authority:** <br>Commissioner<br>|**Originating Division:** <br>Health Services Division<br>(Mental Health)|**Access Listing:**<br>Level I: All Access|



C. **Assaultive Behavior**    - Behavior patterns characterized by destructiveness or

violence directed towards an object or person.


D. **Hardened Cell**    - A cell designated and maintained by the facility which contains no

device that could potentially be used by the offender in harming self or others.
Hardened Cells are security focused and most often used by security staff to manage
potentially aggressive and/or violent offenders.


E. **Homicidal Behavior**    - Behavior characterized by the intent to carry out deadly harm

against another.


F. **Mental Health Observations**    - A specified sequence of documented visual

observations of an offender who is experiencing a mental health crisis (i.e.,
continuous observation, irregular fifteen (15) minute watch, etc.)


G. **Suicide Resistant** **Cell**    - An observation cell, Acute Care Unit (ACU) cell, and/or a

Crisis Stabilization Unit (CSU) cell which has been reviewed and certified by the
GDC Central Office of Health Services. Security Resistant Cells are used by mental
health staff to protect the potentially self-injurious and/or suicidal offender from selfharm.


H. **Qualified Mental Health Professional**    - Clinical Director/Psychologists, Mental

Health Unit Managers, Psychiatrists, Advanced Practice Registered Nurses
(APRNs), Licensed Nurses, Social Workers, Marriage and Family Therapists,
Mental Health Counselors/Licensed Professional Counselors, Mental Health
Behavior Specialists and others who, by virtue of their education, credentials and
experience are permitted by law to evaluate and care for the mental health needs of
offenders.

**III.** **Statement of Policy and Applicable Procedures:**

A. Management of the Aggressive Mentally Ill:


1. Offenders displaying assaultive physical behavior potentially attributable to a

mental illness, head trauma, or an adverse medication reaction, will be referred to
an appropriate mental health provider for evaluation and treatment; and


2. Interventions will be determined as clinically indicated for the appropriate level

of mental health services. Security considerations and program availability will
be factors considered in determining placement.


|GEORGIA DEPARTMENT OF CORRECTIONS<br>Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|
|**Policy Number:** 508.28|**Effective Date:** 8/12/2019|**Page Number:** 3 of 10|
|**Authority:** <br>Commissioner<br>|**Originating Division:** <br>Health Services Division<br>(Mental Health)|**Access Listing:**<br>Level I: All Access|



B. Identification and Referral of Potentially Suicidal or Self-Injurious Offenders:


1. If any staff determines that an offender may be suicidal or self-injurious, the

offender will be referred at once to the mental health staff for further assessment
and disposition. A written record of referral and disposition will be made using
either Attachment 1, Mental Health Referral (M35-01-01), as referenced in SOP
508.19, Mental Health Referral and Triage, or the Consultation Request Form
(PI-2007), as referenced in SOP 507.04.10, Consultations and Procedures, and
placed in the medical and mental health record;

2. At facilities with mental health units, offenders who demonstrate suicidal

behaviors, verbalize suicidal intent or are otherwise deemed to be suicidal or selfinjurious will be assessed by a Qualified Mental Health Professional to determine
the potential for self-harm. Consideration of the history and seriousness of
previous suicide attempts, suicidal behaviors, method of potential self-harm,
mental status, and the presence or absence of a plan for taking one's life will
determine interventions and precautions to be taken;


3. Assessment of suicide risk will include completion of Attachment 1, Suicide

Risk Assessment Instrument (Form M69-01-01 from SOP 508.29) within twentyfour (24) hours or the next working day of identification of potentially suicidal or
self-injurious offenders. This form must also be completed a second time upon
discharge from Suicide Precautions. Any Qualified Mental Health Professional
may complete the following sections of the Suicide Risk Assessment Instrument:
Reasons for Referral, History of Suicidal Behavior, Risk Factors and Protective
Factors. An Upper Level Provider must complete Risk Level and Intervention
Guidelines, or Discharge from Suicide Precautions, Recommendations and
Upper Level Provider signature and date;


4. At facilities without mental health units, offenders who demonstrate a risk factor

for suicidal/self-injurious behavior will be assessed by medical and/or general
population counseling staff in consultation with the mental health staff at the
designated mental health facility in their catchment;


5. At facilities without mental health units, mental health staff from the catchment

facility will provide guidance and determine when the offender will be
transported for an evaluation. The catchment facility mental health staff will also
provide guidance for appropriate precautionary measures pending transfer.
Standard Operating Procedures 209.04, Use of Force and Restraint for Offender


|GEORGIA DEPARTMENT OF CORRECTIONS<br>Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|
|**Policy Number:** 508.28|**Effective Date:** 8/12/2019|**Page Number:** 4 of 10|
|**Authority:** <br>Commissioner<br>|**Originating Division:** <br>Health Services Division<br>(Mental Health)|**Access Listing:**<br>Level I: All Access|



Control and 209.05, Stripped Cells and Temporary Confiscation of Personal
Property may be used to keep the offender safe.


C. Housing and Monitoring the Suicidal, Self-injurious and Assaultive Mentally Ill

Offender:


1. The goal of placing offenders in a stabilization unit is to keep them safe, enable

them to regain control of themselves and return to the least restrictive
environment consistent with their security requirements.

2. There are five stages of stabilization. The most restrictive/highest level of

stabilization is the Secure Psychiatric Facility, while the Isolation/Segregation
Cell is the least restrictive/lowest level of stabilization.


a. Secure Psychiatric Facility (Highest Stabilization Level): The Secure

Psychiatric Facility’s primary function is evaluation and stabilization.
Offenders eligible for placement are those who pose an overt danger to
themselves and/or others and who were unable to stabilize within a Crisis
Stabilization Unit in a clinically indicated timeframe. Refer to SOP 508.25
for documentation requirements.

D. Crisis Stabilization Unit (CSU):


1. The primary function of CSU is stabilization, transition, and observation.


2. Offenders admitted to this unit are those who pose an overt danger to themselves

and/or others or those who have injured themselves and need medical and
psychiatric attention;

3. CSU beds are in an infirmary. Mental Health staff determines whether

placement in a CSU cell is necessary and appropriate. Cells must be Suicide
Resistant and certified as such by the Statewide Mental Health Director/designee,
using Attachment 6, Cell Analysis Form (M68-01-10);

4. Length of stay should not generally exceed five (5) to seven (7) working days;

5. CSU is the only place where offenders can be placed in restraints.

6. Refer to SOP 508.31 for documentation requirements.


|GEORGIA DEPARTMENT OF CORRECTIONS<br>Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|
|**Policy Number:** 508.28|**Effective Date:** 8/12/2019|**Page Number:** 5 of 10|
|**Authority:** <br>Commissioner<br>|**Originating Division:** <br>Health Services Division<br>(Mental Health)|**Access Listing:**<br>Level I: All Access|


E. Acute Care Unit (ACU):







1. The primary function of ACU is stabilization, transition, and observation.


2. Offenders who are admitted to an Acute Care Unit may be potentially dangerous

to themselves and/or others.

3. Stabilization in this unit is expected to occur in less than fourteen (14) days.

4. Beds are in a stand-alone unit or a Supportive Living Unit (SLU), not an

Infirmary/Crisis Stabilization Unit; however, the facility should also have a
Crisis Stabilization Unit or an identified alternative catchment facility Crisis
Stabilization Unit available for use if necessary.

5. Admission and discharge require concurrence from a Psychiatrist/Psychologist.

This concurrence must be documented in a progress note.

6. Mental Health staff determines whether placement in an Acute Care Unit cell is

necessary and appropriate. Cells which are not located in isolation/segregation
units must be “suicide resistant” and certified by the Statewide Mental Health
Director/designee, using Attachment 6, Cell Analysis Form (M68-01-10); and

7. Refer to SOP 508.31 for documentation requirements.

F. Observation Cells:


1. The primary functions of Observation Cells are safety and temporary holding.

Offenders are admitted out of necessity in instances where the offender needs to
be placed in an Acute Care Unit or Crisis Stabilization Unit but due to other
safety considerations, immediate movement is not possible. Stabilization may be
a by-product of placement.

2. Placement in an Observation Cell is a way for facility staff members to

temporarily keep the offender safe until a crisis placement cell is available.

3. Security staff and Mental Health staff shall jointly decide whether placement in

an observation cell is necessary and appropriate. Observation Cells which are
located in isolation/segregation units must be “suicide resistant” and certified as
Observation Cells by the State Mental Health Director/designee, using
Attachment 6, Cell Analysis Form (M68-01-10);


|GEORGIA DEPARTMENT OF CORRECTIONS<br>Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|
|**Policy Number:** 508.28|**Effective Date:** 8/12/2019|**Page Number:** 6 of 10|
|**Authority:** <br>Commissioner<br>|**Originating Division:** <br>Health Services Division<br>(Mental Health)|**Access Listing:**<br>Level I: All Access|



4. To ensure the safety of the offender and others, facility staff may use procedures

such as one-on-one continuous observation, closed-front cell, security strip,
security restraints, etc. These decisions are made jointly by mental health staff
and security staff.


5. Admission and discharge from an Observation Cell requires concurrence from a

Psychiatrist/Psychologist. This concurrence must be documented in a progress
note.

6. Offenders placed in Observation Cells must be on a fifteen (15) minute watch at

minimum;

7. Placement is not to exceed twenty-four (24) hours. If it exceeds twenty-four (24)

hours, Attachment 5, Notification to Warden of Observation (M68-01-05), must
be sent to the Warden, Regional Director, and Statewide Mental Health
Director/designee with information justifying placement beyond twenty-four (24)
hours;

8. If admitted during off-duty hours, a Qualified Mental Health Provider must

evaluate the offender within twelve (12) hours of placement; and


9. If an offender is admitted twice in a seven (7) day period, then they must be

transferred to an Acute Care Unit or a Crisis Stabilization Unit.

G. Data Collection:


1. Attachment 3, Observation Cell Admission Log (M68-01-03), will be maintained

and will include the following data:


a. Offender’s Name and ID number;

b. Date/time of placement;

c. Date/Time of release (not to exceed 24 hours);

d. Placement upon release (facility or dorm); and

e. Comments (reason placement exceeded 24 hours; reason offender was not

moved; etc.)


|GEORGIA DEPARTMENT OF CORRECTIONS<br>Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|
|**Policy Number:** 508.28|**Effective Date:** 8/12/2019|**Page Number:** 7 of 10|
|**Authority:** <br>Commissioner<br>|**Originating Division:** <br>Health Services Division<br>(Mental Health)|**Access Listing:**<br>Level I: All Access|



H. Isolation/Segregation Cells (Lowest Stabilization Level):


1. The primary function of the Isolation/Segregation Cell is to bring assaultive

Mental Health offenders under control in order to protect the safety and security
of employees, offenders and the facility/center as a whole.


2. At facilities without appropriate mental health units, the isolation/segregation cell

may function as an observation cell until the offender is able to be transported to
a Mental Health facility for stabilization;

3. Prior to placement or shortly thereafter the assaultive Mental Health offender

must be evaluated by a Qualified Mental Health Professional who discusses the
case with a Psychiatrist/APRN/Psychologist and documents the consultation in a
progress note. The progress note must be filed in:


a. Section 1 of the mental health record; and


b. Section 5 of the medical record.


4. Should the Psychiatrist/Psychologist not be at the facility, the case is to be

discussed with the on-call Psychiatrist;

5. The clinicians must determine the appropriate level of stabilization needed. This

decision should be based on the following information:


a. A description of the infraction;


b. Diagnosis(es);


c. Medication;


d. Medication adherence;


e. Self-injurious behavior; and


f. Self-injurious history, etc.;

6. When the clinicians decide that the behavior is not the result of a mental illness

and defers to security in order to regain and maintain control of an assaultive
Mental Health offender:


|GEORGIA DEPARTMENT OF CORRECTIONS<br>Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|
|**Policy Number:** 508.28|**Effective Date:** 8/12/2019|**Page Number:** 8 of 10|
|**Authority:** <br>Commissioner<br>|**Originating Division:** <br>Health Services Division<br>(Mental Health)|**Access Listing:**<br>Level I: All Access|



a. The clinician is not nullifying Mental Health staff’s responsibility; and


b. Mental health staff will continue to assess and treat the assaultive offender.

7. Mental Health and security staff must work hand-in-hand in the provision of

Mental Health services and the protection of staff and offenders;

8. To ensure the safety of the offender and others, facility staff may use procedures

such as one-on-one continuous observation, closed-front cell, Hardened Cell,
security strip, security restraints, etc. These decisions shall be made jointly by
mental health and security.

9. A Qualified Mental Health Professional must make and document daily rounds

on offenders in a progress note (Refer to SOP 508.20 Mental Health Rounds in
Isolation);


10. If the offender continues to be assaultive, the Qualified Mental Health

Professional must consult with a Psychiatrist/APRN/Psychologist on whether it is
appropriate to move the offender to a higher level of stabilization;

11. Offenders classified as Mental Health Level II/III can be placed in the

Isolation/Segregation cell for behavioral control:


a. Offenders classified as Level IV should not be placed in the

Isolation/Segregation cell;

b. Alternative sanctions should be utilized; and

c. A disciplinary report evaluation must be performed on Level III/IV offenders

(Refer to SOP 508.18 Mental Health Discipline Procedures for Levels II IV).

12. Documentation of all interventions with suicidal/self-injurious and assaultive

offenders will be made in:


a. Section 1 and/or Section 4 of the mental health record; and

b.  Section 5 of the medical record.

13. Mental Health staff will be responsible for coordinating appropriate follow-up

care and management.


|GEORGIA DEPARTMENT OF CORRECTIONS<br>Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|
|**Policy Number:** 508.28|**Effective Date:** 8/12/2019|**Page Number:** 9 of 10|
|**Authority:** <br>Commissioner<br>|**Originating Division:** <br>Health Services Division<br>(Mental Health)|**Access Listing:**<br>Level I: All Access|


I.  Notification and Review:







1. Whenever there is severe self-injurious behavior, Attachment 2, Critical Incident

Form (M03-01-02), will be completed and faxed to the State Mental Health
Director/designee within forty-eight (48) hours.


a. A copy will be filed in Section 7 of the mental health record, section 5 of the

medical record; and


b. A copy will be forwarded to the Mental Health Unit Manager.

2. When an offender has engaged in self-injurious behavior, Attachment 4,

Suicide/Self-Injurious Behavior Information (M68-01-09), should be completed
and forwarded to the Statewide Mental Health Director/designee within fortyeight (48) hours. If the self-injurious behavior is severe, also complete
Attachment 2, Critical Incident Form (Form M03-01-02 from SOP 508.03).

3. Whenever there is a suicide, Attachment 1, Offender Death Notification Form

(Form M03-01-01 from SOP 508.03) will be completed and faxed, within
twenty-four (24) hours after the incident, to the Statewide Mental Health
Director/designee.


a. A copy is to be filed in Section 7 of the mental health record; and


b. A copy is to be forwarded to the Mental Health Unit Manager.


4. When an offender has committed suicide, Attachment 4, Suicide/Self-Injurious

Behavior Information (M68-01-09), should also be completed and forwarded to
the Statewide Mental Health Director/designee within 24 hours; and

5. In the event of a completed suicide, notification procedures will be invoked

according to procedures 125-2-4-.20, 124-4-4.10, and 124-4-4.l l of the Rules of
the Board of Corrections. See GDC SOP 508.03 Death & Critical Incident
Notification and Investigation.


|GEORGIA DEPARTMENT OF CORRECTIONS<br>Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|**Policy Name:**Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior|
|**Policy Number:** 508.28|**Effective Date:** 8/12/2019|**Page Number:** 10 of 10|
|**Authority:** <br>Commissioner<br>|**Originating Division:** <br>Health Services Division<br>(Mental Health)|**Access Listing:**<br>Level I: All Access|


**V** . **Attachments:**







Attachment 1: Certificate of Approval (M68-01-01)
Attachment 2: Critical Incident Form (M03-01-02)
Attachment 3: Observation Cell Log (M68-01-03)
Attachment 4: Suicide/Self-Injurious Behavior Information (M68-01-09)
Attachment 5: Observation Cell Notification (M68-01-05)
Attachment 6: Cell Analysis Form (M68-01-10)

**VI.** **Record Retention of Forms Relevant to this Policy:**

Upon completion, Attachments 1, 2, 3, and 6 will be maintained in the mental health
area for 10 years. Upon completion, Attachment 4, shall be given to the Statewide
Mental Health Director (original) fax within 48 hours of the incident (24 hours for
suicides). Upon completion, Attachment 5 shall be given to the Warden/Superintendent
(original) and faxed to the Statewide Mental Health Director. Both Attachments, 5 and 6,
shall be placed in the offender’s mental health file. At the end of the offender’s need for
mental health services and/or sentence, the mental health file shall be placed within the
offender’s health record and retained for 10 years.