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SUICIDE D-260 05-25-23 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: SUICIDE PREVENTION NO: D-260 FILE: SUICIDE EFFECTIVE DATE: 02-04-91 REVISED: 12-25-94, 07-04-96, 08-19-98, 11-01-98, 03-01-01, 03-01-04, 03-23-17, 03-30-17, 06-15-18, 07-01-21 AUTHORITY: Sheriff J. Zanoni APPROVED BY: Assistant Sheriff S. McComas REFERENCE: Penal Code Section 6030; California Code of Regulations, Title 15, Sections 1020, 10217 10237 10297 10307 10557 12057 1207, and 1220; Anderson v. County of Kern 45 F.3d 1310 (9th Cir. 1995); Training Curriculum on Suicide Detection and Prevention in Jails and Lockups, National Institute of Corrections, March 1995; and Hall v. County of Fresno, E.D. Cal. No: 1-1 1-CV- 02047-LJO-BAM (2015). PURPOSE: The purpose of this policy is to establish and maintain a suicide prevention and intervention program designed to identify, monitor, and when necessary, provide for emergency response and treatment to those inmates who present a suicide risk while incarcerated at the Fresno County detention facilities. POLICY: It is the policy of the Fresno County Sheriffs Office Jail Division to minimize the incidence of suicide by establishing and maintaining a comprehensive suicide and prevention and intervention program designed to identify inmates who are at risk of suicide and to intervene whenever possible. It is the policy of the Fresno County Sheriffs Office Jail Division that all arrestees and inmates shall be medically screened at the time of intake by a medical staff member for possible signs and symptoms of suicidal behavior. It is the policy of the Fresno County Sheriffs Office Jail Division that all inmates who display signs of suicide risk shall have a comprehensive suicide risk assessment form completed by a mental health clinician to determine if the inmate presents a low, moderate, or high risk of suicide. Page 1 of 12 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: SUICIDE PREVENTION NO: D-260 FILE: SUICIDE PROCEDURES: I. TRAINING Suicide prevention training shall be provided for all staff that have direct contact with inmates. A. All correctional officers are trained in recognition of suicidal risk factors and suicide prevention as part of their initial training upon employment. This training includes verbal, non-verbal, and behavioral cues that indicate a potential suicide and how to respond appropriately. B. Correctional officers shall receive suicide awareness and prevention training annually. All such training shall be provided by a licensed mental health clinician having expertise in correctional suicide prevention and expertise in the use of a suicide risk assessment form. C. All correctional officers are trained in standard basic first aid and are CPR certified. Every housing security station is equipped with emergency equipment, including a first aid kit, protective apparel bags (mask, face shield, suit and gloves), an Ambu-bag (manual resuscitator), and a cut-down knife (to cut through fibrous material). D. Nurses assigned to perform intake screenings (i.e., Booking Nurses) are Registered Nurses (RN's) who have received additional training by a licensed mental health clinician regarding the intake assessment for mental illnesses and suicide risk factors. 11. IDENTIFICATION/ASSESSMENT A. Identification of suicidal inmates begins with the initial screening conducted by the Booking Nurse. Intake screening and assessment provide invaluable information in identifying suicide risk factors. 1. The Intake/Receiving Screening Form shall include a question regarding any history of mental health problems and/or treatment, hospitalizations, and/or current or previous thoughts of self-harm. 2. A notice has been posted in the intake area requesting that arresting/transporting officers advise intake staff if they have knowledge of any relevant information indicative of an arrestee's mental or medical well-being (including suicide risk). Page 2 of 12 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: SUICIDE PREVENTION NO: D-260 FILE: SUICIDE B. The Booking Nurse may make the recommendation to medically reject the arrestee if the arrestee is mentally unstable or otherwise urgently in need of medical/mental health attention that cannot be managed at the Jail. 1. The nurse may contact a mental health clinician for a second opinion on the arrestee's suicide risk level. 2. The nurse may refer the arresting/transporting officer to the Community Regional Medical Center (CRMC) so the arrestee may be examined, stabilized, and returned with medical clearance. (This clearance may be obtained prior to transportation to the jail.) C. Correctional staff members should be alert and aware of the basic signs and symptoms of suicidal behavior. Inmates displaying signs of suicide risk shall be emergently referred to a licensed mental health clinician for an evaluation. (Refer also to Section VI/Intervention.) D. Mental health clinicians shall complete a comprehensive Suicide Risk Assessment form for all inmates who display signs of suicide risk to determine if the inmate presents a low, moderate, or high risk of suicide, and create a corresponding ALERT (i.e., L-Suicide, M-Suicide, H- Suicide) in Offendertrak. ED Mental health clinicians shall complete a new Suicide Risk Assessment form if there are indications of any modification of risk factors, including but not limited to any suicide attempts or expressions of suicidal ideations. III. HOUSING A. Inmates determined by a licensed mental health clinician to be a low-risk for suicide shall be housed with other inmates or, if they cannot be housed with other inmates, in housing where they can be frequently monitored by correctional staff. Such inmates shall be reassessed at least monthly by mental health staff. The reassessment shall occur in a private interview setting, whenever possible. B. Inmates determined to be a moderate-risk for suicide shall be housed with other inmates unless they pose a safety and security threat to other inmates. Moderate-risk inmates shall also be housed in locations that allow correctional staff to observe and communicate with these inmates on a daily basis. Such inmates shall be reassessed at least weekly by Page 3 of 12 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: SUICIDE PREVENTION NO: D-260 FILE: SUICIDE licensed mental health staff. Once the licensed mental health clinician reassigns the inmate to low-risk for suicide, the inmate will be reassessed monthly. The reassessments shall occur in a private interview setting, whenever possible. IV. COMMUNICATION A major component of a successful suicide prevention program is effective and timely communication. A. An inmate may report suicidal ideation to any health care personnel, mental health professional, or custody staff. Custody staff is responsible to: 1. Emergently notify Mental Health (or the on-duty charge nurse) and the supervising sergeant. 2. Document the circumstances in an incident report. B. A licensed mental health clinician will evaluate the inmate, complete a Suicide Risk Assessment form, and proffer their recommendation to the on-duty Watch Commander. If an inmate is at high risk of attempting self-injurious behavior, the mental health clinician will complete a Crisis Management Plan form, which will be provided to the Watch Commander. C. The Watch Commander will convey his/her decision to the Facility Sergeant and ensure that- 1. All Crisis Management Plans are scanned into the Inmate Management Plans folder in the G-drive (G/RefMat/Custody/Inmate Management Plans). 2. An email is sent to all Sergeants and Lieutenants, notifying them of the newly effected plan. 3. If Mental Health staff was not involved in the recommendation and placement of the inmate into the safety cell, the Watch Commander shall ensure that Mental Health staff has been emergently notified. D. If an inmate is to be transferred to a safety cell, the Facility Sergeant will be responsible to notify the Booking Sergeant and the affected housing floor of the impending transfer. The Booking Sergeant shall notify appropriate personnel in Booking and Population Management. Page 4 of 12 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: SUICIDE PREVENTION NO: D-260 FILE: SUICIDE 1. Population Management will initiate a HOUSING ALLOCATION movement into the appropriate safety cell. 2. The Booking I Officer shall ensure that the medical staff assigned to Booking has been notified. 3. The inmate's name, booking number, reason for placement, additional precautions (e.g., "yellow suiter, "spitter," etc.), and any items to be withheld from the inmate shall be written on the board posted outside of the safety cell in which the inmate is placed. E. If an inmate is to be placed on restrictions, the Facility Sergeant will be responsible to- 1. Print all newly enacted Crisis Management Plans, Behavior Management Plans (BMP's), and Administrative Action Reports, as applicable. Copies of all current/applicable forms shall be placed into the "Inmate Management Plan" binder located in the security station of the affected housing floor. The only exception is the South Annex 2D housing unit, where the plans are immediately accessible outside of each individual cell door. 2. Ensure the affected housing floor officers are notified and aware of any newly effected inmate management plan(s). 3. Purge the binder of expired forms, as necessary. FD Appropriate staff is notified when an inmate is removed from a safety cell and reassigned to a housing unit. Mental Health provides follow-up for inmates within twenty-four (24) hours of safety cell removal. The inmate will receive subsequent mental health evaluations at designated intervals, until Mental Health determines that the inmate no longer needs such monitoring (as defined under III/Housing). V. SUICIDE RESTRICTIONS A. If an inmate is at moderate risk of attempting self-injurious behavior, but is not in immediate danger, a licensed mental health clinician may recommend that the inmate be placed on Suicide Precaution/"no sharps." The clinician will be responsible to: Page 5 of 12 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: SUICIDE PREVENTION NO: D-260 FILE: SUICIDE 1. Complete a Crisis Management Plan that documents their recommendation, and indicates the possessions and clothing items that should be removed or kept. The form is submitted to the Watch Commander. 2. Create an ALERT ("Restriction — Mental Health") in Offendertrak. B. If the inmate is placed on "no sharps," the inmate's belongings shall be searched by correctional staff and all items that could be used for self- harm shall be removed from their possession (pencils, razors, staples, eating utensils, etc.). C. Regular jail clothing and bedding may be removed, if recommended by the examining licensed mental health clinician. In such cases, the inmate will be dressed into a safety garment and given an all-in-one bed to replace the traditional blanket and mattress (if determined safe to do so). These items are made of a special fabric that is impervious to being ripped and used for hanging. D. Intermittent direct visual/verbal supervision shall be provided and documented at least once each hour at staggered, random intervals. The documented visual inspections shall be recorded via computer, utilizing the Safety Check System. E. The use of physical restraints (i.e., restraint chairs and handcuffs) are avoided and used only as a last result (e.g., to eliminate the risk of the inmate engaging in self-destructive behavior, such as head banging, etc.). VI. INTERVENTION A. Any time staff suspects a suicide attempt is imminent, they shall- 1. Take reasonable and appropriate precautions to mitigate the ability of the inmate to injure him/herself. 2. Promptly report unusual behavior exhibited by the inmate and any other pertinent information concerning the potentially suicidal inmate to the on-duty charge nurse and the Facility Sergeant as soon as possible. Page 6 of 12 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: SUICIDE PREVENTION NO: D-260 FILE: SUICIDE 3. Consider establishing and maintaining a non-threatening emotionally supportive conversation with the inmate while awaiting assistance. Many times, staff's verbal interaction and availability will be enough to get an inmate over the initial crisis of incarceration. 4. While awaiting appropriate health care and housing decisions, the inmate should be handcuffed and either placed into a secure location or remain under direct and constant supervision. If necessary to restrain a pregnant inmate, the application of restraints shall be restricted to handcuffs to the front of the inmate only. B. If a qualified health care professional is not immediately available, the inmate should be placed in an appropriate and safe location until health care is available. If the inmate does not remain under constant supervision, the inmate shall be visually checked at least twice every thirty (30) minutes at staggered, random intervals. C. An incident report shall be written (I035/Mental Health Interview, or other, as appropriate). The report shall include: 1. The inmate's symptoms/behavior. 2. The action taken. 3. The notifications made, specifically the date, time, and the names of the health services staff and Sergeant notified. VI I. RESPONSE TO SELF-INJURIOUS BEHAVIOR OR SUICIDE ATTEMPT Self-injurious behaviors cause, or are likely to cause, physical self-injury. A suicide attempt is an intentional act that is deliberately designed to end one's own life. Both are medical emergencies that require immediate and appropriate responses. A. In medical emergencies, the primary objective is to preserve life. Officers are required to provide immediate life support. The responding officer must assess and ensure it is reasonably safe to perform life support by effecting the following actions: 1. Notify the Security Officer. a. State the circumstances and request necessary medical personnel and/or additional officers. Page 7 of 12 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: SUICIDE PREVENTION NO: D-260 FILE: SUICIDE b. Request another officer respond to the location with applicable emergency equipment (e.g, body fluid protective suits, cut-down knife, Ambu-bag, first aid kit). c. Depending on the seriousness of the situation, the discovering officer should call for a Code 33 (emergency — clear the radio channel) and Code Blue (medical emergency). 2. If the incident occurs in a housing unit, direct the remainder of the inmates to return to their cells/bunks. 3. Determine and respond appropriately to any exposed bloodborne pathogens. a. It is suggested and preferred that staff members carry disposable gloves at all times for use in emergency situations. b. When handling inmates who are bleeding, appropriate personal protective equipment should be worn to prevent unnecessary exposure. 4. Take appropriate action to intervene. Determine if there are any significant security threats to self or others (including any circumstances causing harm to the involved inmate), evaluate the risks, and take appropriate action to terminate/resolve the emergency situation. 5. Check the inmate for signs of respiration, heartbeat, level of alertness, etc., and initiate the appropriate lifesaving measures. 6. Although the scene appears to be an attempted suicide, protect and maintain the area as a possible crime scene. (An attempted murder may have occurred and made to appear as a suicide.) Preservation of life shall take priority over preservation of a crime scene. B. The Security Officer shall be responsible to: 1. Immediately call for medical staff and inform them of the circumstances. 2. Immediately call Central Control and advise them of the medical emergency. (Central Control will route the elevator in readiness of responding medical staff.) Page 8 of 12 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: SUICIDE PREVENTION NO: D-260 FILE: SUICIDE 3. Emergently call and notify the Facility Sergeant. 4. Note the time of notifications, as well as the time of arrivals. C. Officers responding to the scene will coordinate securing the scene, if necessary. D. Responding medical personnel will relieve/direct correctional staff and assume primary responsibility for the provision of medical attention and lifesaving efforts. 1. Medical/correctional staff will determine if an ambulance is needed. 2. Central Control will coordinate the call for an ambulance. 3. Medical personnel will coordinate the ongoing CPR/first aid. Custody and medical personnel together are responsible for the continuance of lifesaving efforts for as long as necessary. 4. The CPR/first aid will continue until staff is relieved by medical staff/emergency personnel, the inmate is resuscitated, staff is too exhausted to continue, or the scene becomes unsafe. E. If the inmate needs to be taken to the hospital, the Administrative Sergeant will arrange for an officer to accompany the inmate and notify Population Management. Population Management will initiate a HOUSING ALLOCATION transfer to UM. F. The inmate shall receive a medical and mental health evaluation immediately upon their return to the Jail. G. If death results from a suicide attempt, the Jail Watch Commander will contact the Patrol Watch Commander and request that a detective respond to the Jail. Vill. APPARENT SUICIDE A. When an inmate has apparently committed suicide and there are no life signs present, the emergency shall be handled the same as an attempted suicide, utilizing normal first aid and CPR procedures. Unless the inmate shows obvious signs of irreversible death, the determination cannot be made at the scene as to whether the inmate is in fact dead, without doctor certification. Signs of irreversible death include: Page 9 of 12 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: SUICIDE PREVENTION NO: D-260 FILE: SUICIDE 1. Decapitation 2. Decomposition 3. Postmortem lividity 4. Postmortem rigidity 5. Burned beyond recognition B. The Sergeant notified shall be responsible to retrieve the Safety Check log and maintain it as evidence. IX. POST-SUICIDE ATTEMPTS OR COMPLETED SUICIDE A. The location where a suicide or attempted suicide has occurred should be treated as a crime scene after the inmate has been removed from the area. The area should be secured and access controlled to preserve evidence until the appropriate investigation can be completed. B. The on-duty Watch Commander shall be responsible to notify jail medical/mental health providers to have mental health clinicians respond. Inmates who have been affected by the incident will be provided mental health checks and scheduled for follow-up appointments, as deemed necessary. C. All suicides or attempted suicides shall be documented in an incident report. D. Following the incident, the victim's family shall be notified in accordance with policy B-145/Notification of an Inmate's Family or Friend in the Event of Serious Illness or Injury [FILE: NOTIFY-ILLNESS]. E. All in-custody deaths, including those resulting from suicide, shall be investigated and documented in accordance with policy B-140/Inmate Death [FILE: DEATH]. Dependent upon the circumstances, either the detectives or the Coroner's Unit will be responsible to notify the relatives or friends of the inmate's death. F. Involved staff members shall attend the incident debriefing conducted by the Watch Commander. Page 10 of 12 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: SUICIDE PREVENTION NO: D-260 FILE: SUICIDE X. ADMINISTRATIVE REVIEW A. A multi-disciplinary administrative review of every completed suicide, as well as any serious attempt (i.e., requiring hospitalization or transfer to a behavioral health facility) shall be conducted. Participants will be determined by one of the Jail Division Bureau Commanders. B. The review will include: 1. The circumstances surrounding the incident. 2. All Jail Division policies and procedures relevant to the incident. 3. Identification of any training-related issues. 4. Pertinent medical and mental health reports involving the victim. 5. Safety Check logs. C. The psychiatric medical director, in coordination with the Health Services Administrator, will organize the medical chart and compile a summary of the health events to evaluate if appropriate risk factors were assessed. The treatment plan will be evaluated and assessed. In the event of an actual suicide, a psychological autopsy will be performed by a psychiatrist. D. Jail Command Staff will review the summaries within thirty (30) days and make recommendations, if any, for changes in policy, training, physical plant, medical or mental health services, and operational procedures. E. The Compliance Team will be responsible to monitor and track the progress and completion of any recommended changes. XI. AFTER CARE Although the goal of this policy is to significantly reduce the risk of in- custody deaths, the ongoing care of suicidal inmates after release must also be considered. A. Sentenced inmates who have been identified as a moderate or high level of suicide risk on their most recent comprehensive suicide risk assessment form shall receive an evaluation by a mental health clinician prior to their release to the community (or treatment program) for Page 11 of 12 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: SUICIDE PREVENTION NO: D-260 FILE: SUICIDE appropriate referrals or initiation of an involuntary psychiatric hold pursuant to Welfare and Institutions Code Section 5150. (Refer to policy C-210/Inmate Release from Custody [FILE: RELEASES] for procedures.) B. The same services will be provided to unsentenced inmates provided adequate time is available prior to a legally mandated release. XII. ADDENDUMS Key Suicide Risk Factors (Addendum A) Persons at High Risk for Suicide (Addendum B) Signs and Symptoms of Suicidal Behavior (Addendum C) Do's and Don'ts (Addendum D) Suicide Risk Assessment form (Addendum E) Page 12 of 12