SOP 508.29: Suicide Precautions

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|
|Policy Number: 508.29|Effective Date: 7/1/2020|Page Number: 1 of 10|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
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 may require a heightened observation status will
be identified, assessed and referred for further evaluation and/or appropriate
stabilization/management. This procedure is applicable to all Georgia Department of
Corrections facilities.

II. Authority:

A. GDC Standard Operating Procedures (SOPs): 508.27, Time Out and Physical

Restraints; 508.30, Mental Health Acute Care Unit; 508.31, Mental Health Crisis
Stabilization Unit; 508.19, Mental Health Referral and Triage; 209.04, Use of Force
and Restraint for Offender Control; 209.05, Stripped Cells and Temporary
Confiscation of Personal Property; and 507.04.10, Consultations and Procedures;

B. NCCHC Standards for Health Services in Prisons (2014);

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

Facilities (2015);

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

System: National Institute of Corrections, March 2001;

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

Corrections, June 1995; and

F. ACA Standards: 5-ACI-6A-35 (ref. 4-4373 Mandatory), 5-ACI-6B-08 (ref. 4-4389

(Mandatory), 5-ACI-6E-01 (ref. 4-4416), 4-ALDF-4C-32, 4-ALDF-4C-33, 4-ALDF4D-08 (Mandatory), 4-ACRS-4C-04 (Mandatory), and 4-ACRS-4C-16 (Mandatory).

III. Definitions:

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

intentionally taking one's own life.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|
|Policy Number: 508.29|Effective Date: 7/1/2020|Page Number: 2 of10|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health Services)|Access Listing:
Level I: All Access|

B. Self-Injurious Behavior - Any act or expressed intention of self-injury, for an

apparently non-lethal goal.

C. Assaultive Behavior - Behavior patterns characterized by destructiveness or

violence directed towards an object or person.

D. Hardened Cell - An observation cell, Acute Care Unit (ACU) cell, and/or Crisis

Stabilization Unit (CSU) cell which has been reviewed and certified by the GDC
Central Office of Health Services. The facility maintaining said cell will be issued a
certificate of compliance, and the cell will contain no device that could potentially be
used by the offender in harming either self or others.

E. Mental Health Observations - A specified sequence of documented visual

observations, i.e., one-on-one, continuous observation, 15-minute watch, etc., of an
offender who is experiencing a mental health crisis, which will take place in a
Hardened Cell.

F. Upper Level Provider (ULP) - Providers such as MD/DO, CNS/APRN, PA, or

PhD/Psy.D, who are part of a sub-group of licensed independent practitioners who
are more customarily associated with infirmary settings.

G. Qualified Mental Health Professional - Mental Health Unit Managers,

Psychiatrists, Psychologists, Licensed Registered Nurses, Licensed Professional
Counselors, Social Workers, Marriage and Family Therapists, Mental Health
Counselors, Mental Health Technicians, Mental Health Behavior Specialists and
others who, by virtue of their education, credentials, approved privileges and
experience are permitted by law to evaluate and care for the mental health needs of
offenders.

H. Suicide Precautions - Increased level of clinical intervention and observation to

ensure safety when an offender has demonstrated signs or risks of suicide.

IV. Statement of Policy and Applicable Procedures:

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

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|
|Policy Number: 508.29|Effective Date: 7/1/2020|Page Number: 3 of10|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health Services)|Access Listing:
Level I: All Access|

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 the Mental Health Referral Form (SOP 508.19 Mental Health Referral and
Triage Attachment 1 form M35-01-01) or the Medical Consultation Form (PI2007), 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 the Suicide Risk

Assessment Instrument (Attachment 1 form M69-01-01) within twenty-four (24)
hours or the next working day of identification of potentially suicidal or selfinjurious 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

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|
|Policy Number: 508.29|Effective Date: 7/1/2020|Page Number: 4 of10|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health Services)|Access Listing:
Level I: All Access|

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

B. Housing the Suicidal and Self-Injurious Offender:

1. The goal of placing offenders on Suicide Precautions status is to keep them safe,

enable them to regain control of themselves and return to the lowest level of
supervision consistent with their security requirements.

2. Offenders shall only be placed on a Suicide Precautions status at those facilities

having:

a. Established on-site mental health services, or

b. Hardened Cells.

3. Suicide Precautions are not intended to manage offenders who are primarily

aggressive, agitated due to situational stressors, destroying property or hostile
and threatening others. These aggressive offenders will be managed by other
means that may include time out and/or alternative sanctions in accordance with
GDC policy.

C. Suicide Precautions:

1. Assessment will be used to determine whether the offender’s suicide risk level is

mild or requires Suicide Precautions and appropriate interventions for clinical
contact and housing.

a. If suicide risk is assessed as mild, the offender will be coached on coping

strategies, seeking social support, and problem resolution to help the offender
manage current stressors and emotional distress. An appropriate interval for
mental health follow-up will be established and the offender will be informed
of the best way to access mental health staff if symptoms worsen.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|
|Policy Number: 508.29|Effective Date: 7/1/2020|Page Number: 5 of10|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health Services)|Access Listing:
Level I: All Access|

b. If Suicide Precautions status is warranted, the offender will be placed on

Suicide Precautions. Notification of this status will be made to clinical staff
and relevant security staff. An increased level of clinical contact and
treatment interventions will be instituted until the status is discontinued.
The offender may be placed in a Hardened Cell for a safe housing situation.

D. Monitoring Safety for Offenders on Suicide Precautions:

Safety precautions shall include increased frequency and/or duration of counseling
contact at a minimum of two times per week and more contact if considered
appropriate by the mental health treatment team. Consider referral to a suicide
prevention group in consultation with the clinical supervisor and/or treatment team.
Consider pharmacological intervention, if not currently on psychotropic medication.
Carefully document clinical status and interventions. Inform appropriate security
and on-call staff as needed. Those offenders on Suicide Precautions will be
documented in the Suicide Precaution Log (Attachment 5 form M69-01-05).
Information in the log will include the offender’s identifying information, assigned
mental health counselor, beginning and ending dates of placement on Suicide
Precautions status, facility where Suicide Precautions were initiated and the name of
the Upper Level Provider who initiated and/or removed the offender from Suicide
Precautions status.

E. Property Restriction and Clothing:

1. Property and clothing potentially available for those in Hardened Cells where

Suicide Precautions occur will be suicide-resistant garments, booties and suicideresistant bedding (and appropriate resources for females during menses).
Provisions are made to supply the offender with a security garment that will
promote offender safety in a way that is designed to prevent humiliation and
degradation. The person will have no other property unless modification (i.e.
additional items) is allowed based on the documented direction of an Upper
Level Provider. This is to be determined on an individual basis.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|
|Policy Number: 508.29|Effective Date: 7/1/2020|Page Number: 6 of10|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health Services)|Access Listing:
Level I: All Access|

2. If an offender is placed in a Hardened Cell and there is no clinical reason to

restrict property or clothing, the Upper Level Provider will give a directive for
the offender to have clothing and property deemed clinically appropriate (e.g.,
jumpsuit, shoes without laces, food tray, etc.). It is strongly suggested a door
sheet be posted indicating the property directed by the Upper Level Provider.
Mental health staff should communicate and coordinate door sheets with medical
and security staff.

F. Provision of Food While on Suicide Precautions:

Facilities shall designate that the default food for those in Hardened Cells will be
“finger foods”. As with property and clothing, this may be modified by the Upper
Level Provider on an individual basis.

G. Activities During Suicide Precautions:

1. The offender on Suicide Precautions status will generally be restricted to a

Hardened Cell but may attend activities directly supervised by mental health staff
that promote wellness.

2. When safe and clinically appropriate, the offender may leave the Hardened Cell

for activities such as clinical appointments, group therapy and activity therapy.
Security concerns shall be carefully considered for these activities.

3. Clinical activities must be determined by the Suicide Precautions Treatment Plan.

(Attachment 2 form M69-01-02).

H. Contact with Offenders Housed in Hardened Cells for Suicide Precautions:

1. Regular business week working hours at a facility:

a. Daily rounds by Upper Level Provider(s); and

b. Daily clinical contacts by mental health counselor.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|
|Policy Number: 508.29|Effective Date: 7/1/2020|Page Number: 7 of10|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health Services)|Access Listing:
Level I: All Access|

2. Weekends and holidays:

a. A Qualified Mental Health Professional or the facility’s assigned mental

health duty officer will perform daily, on-site rounds on individuals on
Suicide Precautions status. At those facilities where there is a mental health
nurse, or a nurse who is experienced with the mental health program,
weekend and holiday rounds may be completed by that nurse in consultation
with an Upper Level Provider and the mental health duty officer (or
designated mental health counselor). Should the nurse be unable to complete
said rounds it is the responsibility of the mental health duty officer to
complete them. Upon completion of rounds, phone consultation with an
Upper Level Provider shall occur to determine if any changes/modifications
to Suicide Precautions Treatment Plan (Attachment 2 form M69-01-02) are
warranted at that time. Weekend and holiday rounds are to be documented
both in the mental health duty officer logbook and in a Mental Health
Progress Note (SOP 508.10 Confidentiality of Mental Health Records
Attachment 2 form M20-02-02).

I. Frequency of Watch on Suicide Precautions:

1. Offenders housed in a Hardened Cell: A specific time frame, such as every 15

minutes at random, every 5 minutes, 1:1, or line of sight, will be initially
recommended by the Qualified Mental Health Professional and then confirmed
by the Upper Level Provider once the Upper Level Provider is consulted;

2. Offenders housed outside of a Hardened Cell: The frequency of contact will be at

least twice weekly by Qualified Mental Health Professional(s) until the Suicide
Precautions status changes;

J. Initiation of Suicide Precautions:

1. Staff with concern that an offender is suicidal or self-injurious will take

appropriate steps to keep the offender safe and consult with mental health staff as
soon as possible to determine necessary Suicide Precautions’ placement.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|
|Policy Number: 508.29|Effective Date: 7/1/2020|Page Number: 8 of10|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health Services)|Access Listing:
Level I: All Access|

2. If a mental health counselor identifies suicide risk, that person may initiate

Suicide Precautions.

3. Within an hour or as soon as is practical, an Upper Level Provider shall be

consulted. Continuation of Suicide Precautions beyond mild risk requires
consultation and agreement of an Upper Level Provider.

4. Identifying or placing an offender on Suicide Precautions status does not require

a medical order. Initiating Suicide Precautions is a behavioral directive that any
Qualified Mental Health Professional can initiate, but only an Upper Level
Provider can determine and direct official placement, continuation, and/or
discontinuation of Suicide Precautions in a medical or non-medical setting.
Suicide Precautions Rounds (Attachment 3 form M69-01-03) shall be used by the
Upper Level Provider during rounds for an offender who has been placed on
Suicide Precautions status and is being housed in an ACU or CSU cell.

K. Transfer from Suicide Precautions in an Observation Hardened Cell to an Urgent

Care Hardened Cell (ACU/CSU):

1. The offender in this transfer status is expected to go to an Acute Care Unit or

Crisis Stabilization Unit as soon as one is available and transportation can safely
be arranged. There may be times when it is safer not to transport the offender
immediately (at night or in bad weather) or when Acute Care Unit or Crisis
Stabilization Unit bed space is not available, and the offender must be managed
safely at the initiating facility until safe transportation or an available bed is
arranged.

2. Improvement and clinical stability may be a byproduct of this transfer status. If,

during the process of arranging safe transportation, the offender’s clinical status
significantly improves, release from Suicide Precautions may be clinically
indicated and the Suicide Precautions status may be discontinued.

L. Discontinuation of/Discharge from Suicide Precautions:

1. Suicide Precautions is intended to take measures to keep a person expressing

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|
|Policy Number: 508.29|Effective Date: 7/1/2020|Page Number: 9 of10|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health Services)|Access Listing:
Level I: All Access|

suicidal thoughts or exhibiting suicidal behaviors safe and to take measures that
will help alleviate the suicidal/self-injurious behaviors and risk. It is therefore
expected that Suicide Precautions will continue as long as it is determined to be
needed.

2. An Upper Level Provider in consultation with other mental health team members

will determine when it is clinically appropriate and safe to:

a. Give property and clothing back;

b. Allow a food tray;

c. Participate in activities;

d. Decrease frequency of watch; and/or

e. Discharge from Suicide Precautions. At this time, the Suicide Risk

Assessment Instrument (Attachment 1 form M69-01-01) must be completed
and findings to support discontinuation of Suicide Precautions must be
documented.

3. When discontinuing Suicide Precautions, the offender may be continued on an

increased contact status if clinically appropriate. This shall be reflected as a
problem on the Comprehensive Treatment Plan (SOP 508.21 Treatment Plans
Attachment 2 form M50-01-02), with corresponding goal(s) and intervention(s)
noted.

M. Suicide Prevention Training:

All mental health staff, including licensed staff, unlicensed staff, and clinical
consultants, will be required to attend the GDC annual Suicide Prevention training
and/or in-service training focused on Suicide Prevention.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|Policy Name:Suicide Precautions|
|Policy Number: 508.29|Effective Date: 7/1/2020|Page Number: 10 of10|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health Services)|Access Listing:
Level I: All Access|

V. Attachments:

Attachment 1: Suicide Risk Assessment Instrument (M69-01-01)
Attachment 2: Suicide Precautions Treatment Plan (M69-01-02)
Attachment 3: Suicide Precautions Rounds (M69-01-03)
Attachment 4: Suicide Precaution Log (M69-01-04)

VI. Record Retention of Forms Relevant to this Policy:

Completed forms, Attachments 1 - 3 shall be placed in the offender’s mental health file.
At the end of the offender’s need for mental health services or upon release from GDC
custody, the mental health file shall be placed within the offender’s health record and
retained for 10 years. Upon completion, Attachment 4 shall be maintained in the treating
facility mental health area for four (4) years.