3.16 Suicide Prevention Plan Pursuant to Section 1329

Chapter 3
Section 3.16
Subject 3.16 Suicide Prevention Plan Pursuant to Section 1329
Effective Date 5/19/2023 12:00 AM
  1. The facility administrator, in collaboration with the healthcare and behavioral/Behavioral Health administrators, shall plan and implement written policies and procedures which delineate a Suicide Prevention Plan.  The plan shall consider the needs of youth experiencing past or current trauma.  Suicide prevention responses shall be respectful and in the least invasive manner consistent with the level of suicide risk.  This plan shall be reviewed by the Law Enforcement Medical Committee (LEMC) once a year minimally, or as required. The plan shall include the following elements:
  2. Suicide prevention training, in accordance with Section 1322, youth supervision orientation and training (Facility Training Program), and Juvenile Corrections Officer Core Course.
    1. Suicide Prevention Training
      1. Every officer shall receive an initial facility specific orientation on screening youth for risk of suicide, suicide prevention, treatment strategies to include trauma-informed approaches, and responses to suicide attempts.
      2. Every officer will receive a minimum of 4 hours of suicide prevention and training during Juvenile Counselor CORE.
      3. Every officer will receive a yearly 2 hours suicide prevention update.
    2. Screening, Identification Assessment and Precautionary Protocols.
      1. Each youth will be screened for suicide at intake, and as needed during detention, by a Juvenile Service Officer (JSO) prior to housing and have a follow up Behavioral Health screening and risk assessment by the on-duty Behavioral Health Therapist (BHT).
      2. When a youth is brought into custody, the booking officer will ask the arresting/transporting officer if the youth has made any suicidal remarks or is believed to have any suicidal history.
      3. The booking officer will obtain any history of suicidal ideations, attempts, hospitalization, and medication use from the parent or guardian.
      4. The booking officer will inform medical and Behavioral Health staff of any suicidal ideations, attempts, hospitalization, and medication use.
      5.  If a youth presents as a suicide risk, the Safety Protocol will be initiated to ensure the youth’s safety pending the behavioral health assessment.
        1. The Safety Protocol sheet will be completed identifying housing, clothing, showering, programming, eating utensils, and room safety checks.
        2. If an BHT is not on duty to assess the youth, and a youth presents as a suicide risk, Juvenile Hall staff will contact the Behavioral Health Evaluation Team.
      6. During any period of a youth’s detention, they are able to request to speak with an BHT by using the appropriate request forms found on the unit, or verbally asking an officer to complete one for them.
  3. Safety Interventions (Protocol) pursuant to WIC 5585. Procedures to address interventions protocols for youth identified at risk for suicide which may include, but are not limited to:
    1. Housing considerations
      1. The JSO III will house the youth according to their Behavioral Health needs by utilizing Holding and/or a camera room when necessary.
      2. Youth who are on a suicide safety protocol will be housed in Holding in a camera room and be one on one with an officer.
    2. Treatment strategies including trauma-informed approaches.
      1. Treatment strategies are evidence based including trauma informed care, stages of change and motivational interviewing. 
    3. Supervision
      1. Based on the level of suicide risk addressed in the Safety Protocol, appropriate supervision levels will be applied.
      2. Room checks will be outlined in the safety protocol; 5 minutes or 15 minutes.
      3. One on One direct supervision will be instituted when a 5585 is in process. 
      4.  If needed, specifically during sleeping hours, additional staff will be called in to monitor. 
    4. Programming
      1. Youth identified at risk for suicide shall not be denied the opportunity to participate in facility programs, services, and activities which are available to other non-suicidal youth, unless deemed necessary for the safety of the youth or security of the facility.
      2. And deprivation of programs, services, or activities for youth at risk of suicide shall be documented and approved by facility superintendent (Chief Deputy). 
    5. Procedures to instruct youth supervision staff how to respond to youth who exhibit suicidal behaviors.
      1. All threats or comments will be taken seriously.
      2. A youth’s known trauma will be taken into consideration when implementing the safety plan.
      3. All threats or comments by youth to harm themselves or others will immediately be reported to the Behavioral Health, the JSO III/Shift Leader, Supervisor, and medical staff.
      4. The BHT will specify which Safety Protocol precautions will be utilized including housing, clothing, showering, programming, eating utensils, and room safety checks.
      5. The BHT will post the completed Safety Protocol to the door of the youth’s room.  The BHT will make an entry in the JSO’s log, noting that the Safety Protocol has been implemented.
    6. Suicide Risk Protocol: When it is determined that a youth may be a suicide risk:
      1. BHC will call the Psychiatric Crisis Dispatch Center (805-788-2509) to notify them that a youth at the Juvenile Hall is being assessed for suicide and may need a bed in a psychiatric hospital 
      2.  While the Psychiatric Crisis Dispatch Center (CDC)  is seeking a bed, BHC will continue to assess and intervene with the youth to de-escalate and develop a safety plan. 
      3. If the youth does de-escalate and is determined to no longer be at imminent risk of suicide, the BHC will inform the CDC that hospitalization is no longer required.
      4. The youth will remain on Safety Protocol for up to 48 hours 
      5. Safety Protocol sheet will be completed, identifying housing, clothing, showering, programming, eating utensils, and room safety checks
      6. BHC will notify Juvenile Hall staff and initiate the youth being put on Safety Protocol. When it is determined that the youth is a suicide risk:
        1. BHC will confirm with the CDC that youth is a suicide risk 
        2. If designated, BHC will write the 5150/5585 hold. If not designated, BHC will coordinate with the CDC to contact the Behavioral Health Evaluation Team (BHET) to determine if the client meets 5150/5585 criteria.
        3. Fax 5585/5150 hold to SLO Youth Services HIT at 805-781-1265
        4. Probation will transport youth to hospital emergency department for medical clearance
      7. If a youth presents as a suicide risk and BHC is not available to assess the youth:
        1.  Juvenile Hall staff and/or Public Health nurse will the CDC at 805-788-2509
        2. CDC will dispatch the Behavioral Health Evaluation Team (BHET) to the Juvenile Hall
        3. A medical clearance will be required if the youth is placed on 5585/5150
          • Transportation to and from the hospital emergency department, out-of-county inpatient facility, and/or PHF (if youth is 18 or older), will be provided by Probation 
        4. Public Health nursing staff will be notified of a youth’s admittance to and return from the out-of-county inpatient facility (if youth is under 18) or PHF (if the youth is 18 or older) 
          • Nursing staff will complete a Health Services Discharge Summary when a youth is admitted to the out-of-county inpatient facility/PHF
          • Nursing staff will secure prescribed medication upon the youth’s return from the out-of-county inpatient facility/PHF
          • If there is a phone call from the out-of-county inpatient facility/PHF, the Juvenile Services Office will transfer call to the Public Health nurse and/or get a point of contact at the out-of-county inpatient facility/PHF
    7. Once a youth is placed on a 5585/5150 hold and is waiting for placement in an inpatient psychiatric facility the 5585 intervention protocol should be activated to address the needs of the youth:
      1. CDC will call JH control desk (805-781-5389) within 24 hours to arrange telehealth Medication Support appointments with youth on hold as part of the PHF Staff Psychiatrist’s daily rounds
      2. Public Health nursing staff should be available to take medication orders form the PHF staff psychiatrist when needed while the minor is awaiting placement
      3. BHC will meet with the youth a minimum of two times per day while youth is on a 5585/5150 hold.  Contacts may include Seeking Safety, Journaling or another evidence-based practice that focuses on behaviors and symptoms; contacts will be recorded in the electronic health record, supervisor/shift log, and the Behavioral Health log
      4. Public Health nursing staff will check-in with youth two times per day
      5. If a youth has a private therapist and/or psychiatrist, Probation
      6. Rehabilitation services/TBS may be available for youth on psychiatric holds at the Juvenile Hall; confer with SLO Youth Services Program Supervisor and/or Youth Services Division Manager
    8. Youth is reassessed daily by BH, if possible; if the youth no longer meets 5585/5150 criteria, a designated staff (JH BHC or BHET) can rescind the hold in consultation with and approval from PHF Staff Psychiatrist
      1. To contact PHF Staff Psychiatrist call 805-781-4711 and ask to speak with the psychiatrist on duty
      2. Consult with PHF Staff Psychiatrist to get approval to rescind the hold
      3. If PHF Staff Psychiatrist approves, draw a line through the current hold and fax to SLO Youth Services HIT at 805-781-1265
      4. Call CDC at 805-788-2509 to notify that the hold has been rescinded (this will end the bed search)
      5. Update Safety Protocol
      6.  Document that the hold has been rescinded in a Progress Note in electronic health record, BH Notes (if appropriate), and JH Supervisor Log
    9.  All youth who return from an inpatient stay will be placed on a Safety Protocol for 48 hours.
      1. Safety protocol may be adjusted by the BHC to reflect the required level of supervision.
      2. The youth will be assessed by a BHC at the earliest possible time following their return to the Juvenile Hall
      3. Prior to being taken off the Safety Protocol, the youth and BHC will develop a safety plan.
      4. Safety plan will be kept on file in the Behavioral Health Office at the Juvenile Hall. 
        • NOTE:  Implementation and discontinuation of the Safety Protocol requires the signatures of the on-duty Supervising Deputy Probation Officer (SDPO) or JSO III, Public Health Nurse, and BHT.
  4. ​​​Suicide Attempt:
    1. Radio “Code 3 Medical” identifying your location.
    2. All other youth shall immediately be secured in their rooms.
    3. Do not enter the youth’s room until backup has arrived.  It may be a trap.
    4. Separate the youth from the source of threat.
    5. If medical and Behavioral Health staff are in the building, request medical and Behavioral Health staff to assess the youth when safe to do so.
    6. If determined to be necessary by medical staff or the highest-ranking officer, request Control to call 911 and request immediate medical response to the facility.
    7. The responding officer(s) shall commence lifesaving care until Emergency Medical First Responders arrive and either direct that care be discontinued or relieve the responding officer(s).
    8. Once 911 is contacted, the Incident Commander or his/her designee shall be prepared to provide the following information:
      1. Youth’s age, gender, approximate weight, and symptoms.
      2. Any existing medical conditions if known.
      3. Prescribed medication if known.
      4. Specific directions to the facility if requested.
    9. Officers will post at the designated location to direct EMS to the appropriate entrance. (Side gate parallel to Hwy 1 or CVA garden/yard.)  
    10. The on-duty or on-call Supervisor shall immediately notify the Chief Deputy of the Custody Division, who will contact the Assistant Chief Probation Officer, and Chief Probation Officer.  Once the Chief Probation Officer has been notified, the Assistant Chief Probation Officer or designee shall notify by telephone the involved youth’s parents/guardians, or appropriate other.
    11. If a suicide attempt does not rise to the level of calling EMS, ALL youth need to be cleared by the hospital emergency room doctor prior to being transported to an in-patient facility.
  5. Documentation 
    1. All suicide attempts will be documented in a Juvenile Hall Incident Report and Use of Force Report as necessary. 
  6. Critical Incident Debrief
    1. All involved staff will be offered to debrief the incident with a trained therapist.
    2. All staff will be given referrals to the Employee Assistance Program (1-800-999-7222); AnthemEAP.com
    3. If youth are involved with incident, they will have access to Behavioral Health staff.
    4. A process for administrative review of the circumstances and responses proceeding, during and after the critical incidents shall be implemented. 
    5. If deemed necessary, An Internal Administration Investigation Team will conduct a thorough investigation of any suicide and attempted suicide and submit a report to the Chief Probation Officer.  The report may suggest operational procedural changes, if any are identified.
    6. The Chief Probation Officer, Assistant Chief, and/the Chief Deputy of the Custody division, along with Behavioral Health and medical administrator, responsible physician and other health care and supervision staff shall review the report.
    7. If the suicide attempt results in a death, the death in custody policy and procedure (section 4.2) will be followed.
    8. Corrective action will be taken when necessary
  7. Transition Plans
    1.  If a youth has an open Behavioral Health case, the BHTs at the Juvenile Hall will work with youth, the youth’s family, and staff at SLO County Behavioral Health clinics to assure appropriate transition planning for youth being released from Juvenile Hall and needing continued Behavioral Health services.
    2. Public Health nursing staff completes a Health Services Discharge Summary that is sent with the youth and includes information about medication that youth is taking and, when appropriate, instructions to follow up with Behavioral Health to schedule an appointment as soon as possible.
    3. Referrals are made to Behavioral Health providers outside SLO County Behavioral Health when indicated.