OAR 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, and evidence of psychosis or other acute mental health emergency. (2) Training: All employees having direct contact with adults in custody will receive suicide prevention training. (a) Suicide warning signs, prevention strategies, and response procedures will be present in New Employee Orientation 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 employees in special housing units where adults in custody with mental illness are at high risk for suicide (3) Referral: Adults in custody with significant potential for self-directed violence or who are displaying suicide warning signs should be referred to Behavioral Health Services for evaluation. (4) Assessment: Any department employee, 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 a registered nurse in consultation with a mental health provider, will then determine if suicide risk is present. (a) When an adult in custody is placed on suicide watch or suicide close observation, the adult in custody should be reassessed by a registered nurse every four hours and the placement reviewed by a mental health provider within 24 hours, in person or by phone, and at least 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 employees are on duty, or at the end of the last shift and the beginning of the next shift if there is more than four hours without nursing employees on duty. During the interim, specific written instructions shall be given to the officer-in-charge regarding what actions should be taken if the adult in custody's mental status appears to deteriorate, or if any acts of self-directed violence are carried out. (c) All suicide assessment, reassessments, adult in custody responses, as well as any written instructions which are given to the officer-in-charge, will be documented in the adult in custody’s Health Services file. (5) Monitoring - Suicide Watch (high risk): The officer-in-charge shall be responsible for placing an adult in custody on suicide watch based on instruction from a mental health provider or from a 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 adult in custody on suicide watch shall always be under continuous and unobstructed one-to-one observation. (b) When an adult in custody is placed on suicide watch, the officer-in-charge shall remove from the adult in custody’s living area any items that pose a threat for self-directed violence, based on instruction from a mental health provider or from a registered nurse in consultation with a mental health provider. (c) Any adult in custody placed on suicide watch will remain 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 adult in custody on suicide watch past 48 hours, the Behavioral Health Services manager will consult with Mental Health Infirmary to determine whether a Mental Health Infirmary referral is clinically indicated. (6) Monitoring - Suicide Close Observation (moderate risk): The officer-in-charge shall be responsible for placing an adult in custody on suicide close observation based on instruction from a mental health provider or from 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 adult in custody at staggered intervals, not to exceed 15 minutes (for example, 9:15, 9:25, 9:34, 9:49, 10:00). (b) When an adult in custody is placed on suicide close observation, the officer-in-charge shall remove from the adult in custody’s living area items that pose a threat for self-directed violence based on instruction from a mental health provider or from a registered nurse in consultation with a mental health provider. (c) Any adult in custody placed on suicide close observation will remain 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: Adults in custody on suicide watch or suicide close observation may be housed in a segregation cell, special housing, or other cell modified and designated for suicide prevention. The cell must provide an unobstructed view of the adult in custody so they can be observed either continuously or at staggered intervals, as required. Property may be restricted as instructed. (a) A mental health provider should be consulted to determine the most appropriate housing for the adult in custody. If, after this determination, a mental health provider or a registered nurse in consultation with a mental health provider, concludes that the adult in custody cannot be safely maintained at the current facility while on suicide watch or suicide close observation (particularly in facilities without 24-hour nursing coverage), arrangements will be made to transfer the adult in custody 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 adult in custody arrives at the receiving facility. (8) Communication: Throughout the process of suicide risk assessment and intervention, department employees and mental health providers will work closely together to ensure adequate and effective communication. (9) Intervention: If an employee observes an adult in custody actively engaging in self-directed violence, the following steps will be followed using universal blood and body fluid precautions: (a) Call for assistance. (b) If it is a hanging, the employee shall immediately cut and remove any ligatures or other tools used to restrict breathing or blood circulation. (c) Emergency first aid procedures should be followed in the event of any self-directed violence and should be continued until Medical Services employees arrive and give further instructions. (d) First aid procedures will be continued until relieved by Medical Services employees regardless of belief that the adult in custody 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 Behavioral Health Services manager or designee for the facility where the attempted suicide took place. In the event of a completed suicide, the notification will include the Behavioral Health Services manager or designee and the Behavioral Health Services Administrator or designee for the facility where the completed suicide took place. (11) The department’s rules on Death (AIC) (OAR 291-027) and Emergency Preparedness (OAR 291-053) will be followed in the event of a completed suicide.