36C25819R0003-004.pdf

Phoenix VA Health Care System Phoenix, Arizona

Policy Memorandum No. 122-19 March 15, 2017

SUICIDE AND SUICIDE-RELATED BEHAVIOR

1. PURPOSE: To establish policy and procedures for the prevention and management of suicidal behavior among Veteran patients receiving services from staff in the Phoenix VA Health Care System (PVAHCS) or Community-Based Outpatient Clinics (CBOCs )/programs.

2. POLICY: The medical center will make every reasonable effort to prevent its patients from carrying out impulses or plans directed toward self-injury.

3. DEFINITIONS AND BACKGROUND:

a. Clinician: A clinician is a health care professional that works as the primary (Mental Health, Primary Care, etc.) caregiver of a patient in a hospital , skilled nursing facility, clinic, or patient's home.

b. Danger to Others: Danger to others means that the person's judgment is impaired and his/her behavior can reasonably be expected , on the basis of competent medical opinion, to result in serious physical harm to others.

NOTE: There is both a duty to protect and a duty to warn the intended victim(s).

c. Danger to Self:

1) Behavior that constitutes a danger of inflicting serious harm upon oneself, including attempted suicide or the serious threat thereof, if the threat is such that, when considered in the light of its context and in consideration of the individual 's previous acts, it is substantially supportive of an expectation that the threat will be carried out.

2) Behavior that without hospitalization will result in serious physical harm or serious illness to the person.

d. Direct Observation: Close direct visual observation of a patient by a single dedicated caregiver.

e. High-Risk Patient: A patient, who is a danger to self or others due to suicidal behavior, homicidal behavior, confusion, dementia or impaired decision making capacity. The level of risk in which suicidal behavior is likely within the next 24 hours.

f. Homicidal Ideation: Any self reported thought of ending life of another individual.

Policy Memorandum No. 122-19 March 15, 2017

g. Imminent Risk: Level of risk at which suicidal behavior is thought likely within the next 72 hours unless interventions or safety precautions are taken.

h. Interrupted by Self or Other: A person who takes steps to injure self but is stopped by self/or another person prior to fatal injury. The interruption may occur at any point.

i. Involuntary Patient: A person who is assessed to be a danger to self or to others, or is Persistently or Acutely Disabled (PAD), and who is unwilling or unable to undergo voluntary treatment or evaluation as a result of a mental disorder.

j . Lethality: Extent to which the method of self-harm is a medical danger to life.

k. Licensed Independent Practioner: Physician, psychologist, social worker, nurse practitioner, physician assistant or any other individual permitted by law and the organization to provide care and services without direction or supervision within the scope of the individual's license and consistent with individually granted clinical privileges.

I. Medical Hold: A 24-hour (excluding weekends and holidays) period for clinical observation and involuntary inpatient hospital admission of patients determined to be a danger to self or others. This period of time is utilized to safeguard the patient during the initiation of the formal application for court-ordered treatment (See Policy Memorandum MH&BSS/116A-7). A medical hold also applies to any patient presenting verbalizing suicidal/homicidal ideation. The VA Police Department is to be notified immediately for their assistance in maintaining the patient's safety.

m. Missing Patient: An at-risk patient who is unaccounted for and cannot be located.

n. One-to-One Observation: Staff member stays with patient in 1 :1 observation status, maintaining constant observation of the patient. Refer to Policy Memorandum No. 118-10, Patient Safety Observer Policy.

o. Physical Injury: A bodily lesion resulting from acute overexposure to energy (this can be mechanical, thermal, electrical, chemical , or radiant) interacting with the body in amount or rates that exceed the threshold of physiological tolerance (e.g. bodily harm due to suffocation, poisoning or overdoses, lacerations, gunshot wounds, etc.) .

Refer to Classification System for the Centers of Disease Control and Prevention definitions.

p. Preparatory Behavior: Acts of preparation towards engaging in Self-Directed Violence, but before potential for injury has occurred . This can include anything beyond a verbalization or thought, such as assembling a method (e.g. buying a gun, collecting pills) or preparing for one's death by suicide (e.g. writing a suicide note, giving items away).

Policy Memorandum No. 122-19 March 15, 2017

q. Provider: A provider of clinical care is a staff member licensed to deliver health care and services to patients; includes Registered Nurses and Peer Support Technicians.

r. Self Directed Violence: Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself.

s. Suicide: Death caused by self-inflicted injurious behavior with any intent to die as a result of the behavior. COMPLETIONS should be reported by the Suicide Prevention Coordinator on the monthly Attempt and Completion (A&C) report.

t. Suicide Attempt: A non-fatal self-inflicted potentially injurious behavior with any intent to die as a result of the behavior.

u. Suicidal Intent: There is past or present evidence (implicit or explicit) that a individual wishes to die, means to kill him/herself, and understands the probable consequences of his/her actions or potential actions. Suicidal intent can be determined retrospectively and in the absence of suicidal behavior.

v. Suicide Status: The Suicide Prevention Coordinator will determine if a Suicidal Behavior Risk Flag will be placed in the medical record and also when it is to be removed according to protocol.

w. Suicide Watch Protocol: There is a threat of Suicide and the Suicide Watch Protocol must be implemented. This would include 1: 1 monitoring and close/within arm's reach of Veteran unless the LIP deems that unsafe for the observer. The protocol is initiated by a Licensed Professional (i.e., Registered Nurse or Social Worker) until a Licensed Independent Practitioner (LIP) (i.e., Medical Doctor, Doctor of Osteopathy, Physician Assistant or Nurse Practitioner) orders a medical hold if the Veteran becomes involuntary. This order must be written.

x. Voluntary Patient: A person who is willing and able to undergo voluntary treatment or evaluation.

4. BACKGROUND: There are approximately 25 million Veterans in the United States and five million Veterans who receive care within the Veterans Health Administration (VHA) . Data from the Centers for Disease Control and Prevention indicate suicide rates among men between ages of 20 and 65 at approximately 22 per 100,000 persons per year. VHA mental health officials estimate 6,400 suicides per year among Veterans, and 1,600 - 1,800 among Veterans receiving health care from VHA. The rate in the Veteran population is suspected to be higher because a large proportion of our Veteran patients have many of the risk factors that predispose to suicide (e.g., substance abuse, mood and other mental disorders, life circumstance problems, and access to firearms) .

Phoenix VA Health Care System Policy Memorandum No. 122-19 Phoenix, Arizona March 15, 2017

Nearly all the suicidal behavior of our patients occurs outside the medical center;

inpatient suicide is very rare.

Prediction of suicide, like prediction of heart failure, is inaccurate in the individual case.

However, just as with patients at risk for heart attack, clinicians need to recognize patients at risk for suicide and to provide intervention for modifiable risk factors. A growing body of research evidence points to several major suicide risk factors. In addition to the suicide risk factors, clinicians need to be alert for a history of suicidal threats or attempts, a sense of hopelessness, social isolation, recent losses, and chronic medical illness associated with poorly controlled pain, terminal diagnosis, or loss of valued functions and self-esteem. However, it must be recognized that, despite our best efforts, some suicides will occur because the predisposing and/or triggering causes are beyond our influence as there are those Veterans that are reluctant to self disclose current thoughts of suicide.

5. PROCEDURES FOR MANAGING SUICIDAL BEHAVIOR:

a. Suicide Risk Assessment: A clinical evaluation to determine the nature and degree of suicide risk/probability. Advances in the field of suicidology have revealed several key risk factors that should be evaluated in every suicide risk assessment (SRA). The term also refers to the SRA template available at the PVAHCS.

1) An SRA must be completed whenever a patient is seen for the first time in a Mental Health outpatient setting (including the initial assessment conducted when a Veteran is contemplating or investigating eligibility for entering a PVAHCS Mental Health program as well) and updated at any point in the patient's clinical care process.

2) An SRA must be completed within 24 hours of admission and prior to the discharge process for any inpatient mental health admission. An SRA may be completed by any of the following: Psychiatrist, Psychologist, or a Mental Health RN , Social Worker, Physician's Assistant or Nurse Practitioner. The inpatient treating psychiatrist completes the SRA at the time of discharge for their patients.

3) An SRA must be completed whenever a patient for whom suicide has been identified as a clinically relevant issue (e.g . history of recent suicide attempts, flagged as high risk, recently expressed suicidal ideations) undergoes significant clinical decompensation or is judged to be under increased stress.

4) If there are two SRAs that differ in level of risk, both providers will staff the case to determine the best course of treatment for the Veteran. If there is no consensus after the staffing on the level of risk, the SRA with the highest level of risk will be accepted and the Veteran will be treated accordingly. Documentation of the staffing decision and rationale will be documented in the medical record .

Policy Memorandum No. 122-19 March 15, 2017

5) The SRA is done at least annually and if there is an increase in risk level.

b. Outpatient Settings:

1) Patients demonstrating suicidal behavior (serious threats or actual physical self-harm) and/or has expressed acute suicidal ideation on VA premises will not be left unattended during any aspect of the evaluation process. When hospital staff concludes that an outpatient is at imminent risk of suicide, he or she must take immediate and appropriate action to assure life safety. This requirement is of paramount importance. If the patient leaves the area, efforts to locate the patient must be initiated immediately. If the patient is no longer on VA premises, the VA Police must be contacted and they will notify the local municipal police department.

A medical hold , requested of an LIP, also applies to any patient presenting verbalizing suicidal/homicidal ideation. The VA Police Department is to be notified immediately for their assistance in maintaining the patient's safety. Refer to PVAHCS Policy Memorandum No. 116A-08 Mental Health Crisis Evaluation, for additional guidance.

2) When an outpatient on the premises reports or otherwise demonstrates suicidal ideation, urges, or intent, the clinician will record this information in the medical record and add "Suicidal Ideation" into the problem list. A suicide risk assessment will be performed as soon as possible. Refer to PVAHCS Policy Memorandum No. 116A-08 Mental Health Crisis Evaluation, and Policy Memorandum No. 132-13 Management of Wandering and Missing Patients, for additional guidance.

3) VA health care providers who become aware of suicidal threats/behavior in a patient who is not on the premises are responsible for making every reasonable effort to protect the patient's welfare. This will include notification of VA Police who in turn will contact local police.

c. Inpatient (Medical/Surgical) and Long-Term Care Settings: Staff in these settings must be able to recognize patients at risk for suicide and know how to respond appropriately to assure the patient's safety. Physicians in these settings will evaluate patients thought to be suicidal, and, if appropriate, request a psychiatric consultation from Mental Health .

d. Inpatient (Mental Health):

1) On Mental Health inpatient units, if any staff member suspects a patient to be suicidal , the professional nurse will evaluate the need to place the patient on suicidal status and will notify the physician for an evaluation. All patients who are admitted, having had a suicide attempt WITHIN 24 HOURS of admission will be placed on 1 :1 observation status until evaluated by a Psychiatrist. Physician orders establishing Suicide Status will be written . Available levels of Suicide Status

Policy Memorandum No. 122-19 March 15, 2017 are: Suicide Watch (1 :1 arms-length supervision) , Suicide Alert (observation every 15 minutes), and Close Observation (observation every 30 minutes). Patients on Suicide Status will be moved to a room near the nursing station to facilitate observation . Staff will assure that the patient's environment is as free as reasonably possible from objects that could be used to harm self or others. Patients on Suicide Status must be searched and required to surrender any potentially dangerous objects. Finally, articles given to the patient by visitors should be examined for safety hazards.

2) Assignment of Observation : The staff Registered Nurse (RN) assigned to the patient on Suicide Watch status will make a progress note entry every two hours of the patient's statements and observations noted during that time frame. This documentation will continue for the duration that the patient is on suicide watch status until that status is discontinued by the physician. For the patient on suicide alert and close observation status and any 1: 1 status the staff RN assigned to the patient will make a progress note regarding the patients statements and observations noted during the shift, at the end of each tour of duty.

3) Removal from Suicide Status: Suicidal inpatients will be evaluated for removal from Suicide Status when according to the observations of the health care team that imminent suicide risk no longer exists. The unit physician will sign an order to this effect and a Progress Note will be written which describes the patient's change in suicide risk and the actions taken or planned to prevent relapse.

4) The elopement of a patient previously determined to be at high risk for suicide should be handled as a "High Risk Missing Patient Notification." The immediate area should be searched and VA Police should be notified. If the patient is not found , VA Police will notify local police. The family or guardian of the patient should also be notified by the physician or other senior clinician involved in the case. An Electronic Patient Event Report (ePER) noting that there is a missing patient will be initiated.

5) With input from all team members, the Inpatient Care Coordinators will develop an interdisciplinary treatment plan that incorporates all disciplines treating the patient. The treatment plan includes interventions that specifically target the patient's modifiable risk factors for suicide. Whenever possible, the patient's family will be involved in treatment and discharge planning.

6) Discharge of the patient admitted for suicide risk is considered only when the patient's condition and prospective outpatient living environment allow staff to believe that he/she can survive as an outpatient. Whenever possible, and with the agreement of the patient, the family or significant other(s) should be contacted to assist with removal of means of self-harm from the home environment. The inpatient treatment team and patient will collaborate to devise a "Safety Plan", if the patient is agreeable. The Safety Plan will identify triggers and steps to take should an emotional crisis and/or suicidal ideations return. The Safety Plan includes emergency telephone numbers and the patient will be urged to keep it handy at all times. Prior to discharge, the Medical Support Assistant per provider orders will schedule a follow-up appointment (within 5 days of discharge) in outpatient Mental Health. Patients returning to treatment at other VA facilities will have follow-up care coordinated and scheduled prior to discharge by the Social Work personnel on the Acute Psychiatric Unit.

7) The entire course of assessment, re-assessment, planning, and treatment should be thoroughly documented in the patient record. Suicide attempts by hospitalized patients will be reported in the ePER and an Issue Brief as soon as is possible for leadership notification.

8) Patient's Rights: The rights and liberties of the patient must be observed at all times. If it becomes necessary to involuntarily hospitalize the patient in a psychiatric facility, VA staff will adhere to all appropriate Arizona laws (A.R.S. 36- 501 ).

d. Emergency room:

1) The Emergency Department triage nurse will assess all patients presenting with psychiatric complaints or symptoms for suicidal ideation or other potentially high-risk behavioral issues. The assessment will include the following questions:

Now or in the past 2 days, have you thought about or actually harmed yourself or someone else? If the patient's reply leaves room for doubt because of hesitancy or inconsistency with the history or presentation, the RN is to assume the answer is "Yes" and the patient is placed on a 1 :1 observation.

2) If the patient has a positive screen for suicidal or homicidal ideation , the triage nurse will immediately institute 1 :1 observation which will be reviewed by the licensed independent provider (LIP) as soon as possible. All staff members providing patient care are responsible for immediately recording and reporting observations that reflect potential suicide risk to the physician. A 1 :1 observer in the ED may request VA Police presence in the immediate area.

3) If the Veteran reports a suicide attempt occurring within the past twelve months, a Suicide Behavior Report needs to be completed by the MH RN or Social Worker in the ED.

4) In the Emergency Department (ED) mental health patients may be referred to the ED social worker or, if during business hours, the on call psychiatrist may be paged . Evening and weekend/holiday coverage includes an ED social worker and access to the on-call psychiatrist. Those patients expressing suicidal/homicidal

Policy Memorandum No. 122-19 March 15, 2017 ideation remain in the ED until evaluated by an LIP.

5) Patients presenting with Danger To Self /Danger To Others will be encouraged to accept evaluation and treatment voluntarily. If the patient refuses to accept voluntary treatment and demands discharge, the patient is placed on 1: 1 immediately and the VA Police must be notified for assistance. When a LIP places the patient on a Medical Hold, the Veteran must NOT be allowed to leave.

6) The LIP with other available professional staff members will determine if a petition for court-ordered treatment is appropriate and supported with sufficient evaluation and documentation of overt threatening or dangerous behavior. If an application is initiated, the responsible LIP will contact Connections Arizona Urgent Psychiatric Care Center (UPC), provide the pertinent clinical information and request transfer there for evaluation for court-ordered commitment.

Contact Information: Connections Arizona Urgent Psychiatric Care Center 1201 S. 7th Ave, Suite 150, Phoenix, AZ 85007 Phone: (602) 416-7600 Fax Number: (602) 416-7700

Transportation to Connections Arizona Urgent Psychiatric Care Center (one used most frequently, there are other facilities in the community that may also be utilized) will be provided by Phoenix Police who will pick up the patient after the appropriate order is issued by the Urgent Psychiatric Care Center. The original, notarized UPC petition must be hand delivered to UPC before they may act on the petition.

7) Suicidal patients will be evaluated for removal from medical hold when, according to treatment team, imminent suicide risk no longer exists. The current LIP (either in the ED or inpatient unit) will sign an order to remove the Veteran from medical hold.

8) The ED triage nurse will notify the Administrative Officer of the Day (AOD), VA Police Service, the assigned ED physician, the nursing supervisor, and the charge nurse of the presence of a suicidal or homicidal patient on 1: 1 observation in the ED.

a) The charge nurse will assign the patient to a room and will make a 1: 1 direct observation assignment, and notify the LIP of the need for a Medical Hold .

b) The assigned staff member must be familiar with the procedure for suicide 1: 1 observation (Refer to PVAHCS Policy Memorandum No. 118-10, Patient Safety Observer Policy).

c) The assigned staff member immediately evaluates the environment for the presence of potentially dangerous objects and removes such objects.

d) Never leave the patient alone.

e) The assigned staff member will not receive additional assignments.

f) The patient's clothing and belongings will be inventoried by the nursing staff and removed from the patient's room and the patient are to don a hospital gown. The VA Police must be called for assistance if necessary.

g) If additional personnel are required in order to ensure 1 :1 observation, the RN will notify the charge nurse or nurse manager for additional assistance (or nursing officer of the day during the non-business hours). The VA Police Service must also be called and are required to render assistance if it is requested by the ED clinical staff or the nursing supervisor.

h) When non-ED staff members are necessary to support the care of a medical hold patient in the ED, they are required to provide 1: 1 observation until they are released from that responsibility by the ED charge nurse.

i) The VA Police will assist with escorting the high-risk patient to the inpatient psychiatry unit.

j) If the suicidal, homicidal or high-risk patient leaves, efforts to locate the patient must begin immediately and the Missing Patient policy (Policy Memorandum 00/132-13) will be instituted. If the patient is not found to be on VA premises, the VA police will notify the local police for assistance.

In all cases, the physician will summarize the circumstances of the missing patient, including all contacts with staff, in the medical record. Identifiable and potential victims of homicidal ideation MUST be protected and warned, and these efforts equally documented.

g. Suicide Behavior Report:

1) The Suicide Behavior Report (SBR) is completed when suicidal ideations turn into behaviors such as making preparations to suicide: buying a rope to hang oneself; buying a gun and/or ammunition in preparation to harm self; practicing holding gun to one's head to build courage and desensitization to carry out the act;

stockpiling medications in preparation to overdose; searching internet to a specific way to suicide; giving away belongs and/or finalize arrangements with plan of suicide; writing goodbye letters and/or a suicide note; behavior that is thwarted.

2) The SBR is to be completed immediately upon learning of the event. All suicide completions, attempts, and preparatory suicide behavior that occurred within

Policy Memorandum No. 122-19 March 15, 2017 the last 12 months will be subject to the same follow-up procedure and documentation.

3) The Suicide Behavior Report should not be used for suicide ideations that do not involve any suicidal behaviors, or preparatory behaviors such as the ones listed in item #1 above. However, all suicidal ideations should be monitored, documented and treated appropriately, including the development of a Mental Health Safety plan, if indicated.

h. Education and Training:

1) Suicide risk reduction is the responsibility of every PVAHCS employee.

Therefore, each PVAHCS employee is responsible for being alert to potential signs and symptoms that identify at-risk patients and how to alert the appropriate mental health staff (refer to PVAHCS Policy Memorandum No. 116-08, Mental Health Crisis Evaluations).

2) The Operation SAVE Suicide Prevention Training (Signs of suicidal thinking, Ask questions, Validate the person's experience, Encourage Treatment and Expedite getting help) will be provided to all VA Staff during new employee orientation, as this training provides knowledge and procedural guidelines for assisting Veterans who are at risk and helping them get appropriate treatment no matter their enrollment status. In addition to this training clinicians are further assigned in TMS 6201 "Suicide Risk Management Training for Clinicians" to be completed in the first 90 days of hire.

3) The Suicide Prevention Coordinators (SPC) will provide this VA mandated suicide prevention training as well as any needed refresher courses to all clinical and non clinical staff.

4) The SPC will develop an ongoing educational plan for providers , employees, and members of the community on the risk factors and warning signs for suicide in Veterans.

i. High Risk For Suicide Patient Record Flags (PRFs) and Safety Planning:

1) The primary purpose of the High Risk for Suicide PRF is to communicate to VA staff that a Veteran is at high risk for suicide and the presence of a flag should be considered when making treatment decisions.

2) The clinician needs to consider frequent follow-up appointments, involving significant others in care planning and limiting access to means of harming oneself when possible. All clinicians must evaluate and note any changes in Veteran's level of Suicidal Ideation , including planning or intent and assure that the patient's diagnoses and care plan are reviewed in light of this identified risk.

Policy Memorandum No. 122-19 March 15, 2017

3) If you are the Suicide Prevention Coordinator for this Veteran the following procedure must be followed:

a) Over the next 30 days this Veteran needs to be monitored weekly by appointment or phone.

b) After 30 days the Veteran needs to be monitored at least monthly for the next two months. All contacts need to be documented.

4) Frontline staff needs to be aware that if they are concerned about a patient's safety they are to refer to the guidelines in Policy Memorandum No. 116A-08, Mental Health Crisis Evaluations for guidance. After regular business hours, Veterans may be taken to our ED or to any hospital emergency department for care. The absence of a High Risk for Suicide PRF on a patient's record does not indicate that the patient is not at risk for suicide.

5) All staff needs to recognize that any Veteran may be at risk for suicide, regardless of the flag status on the Veteran's chart.

a) The use of any PRF is restricted to addressing immediate clinical safety issues. As such, it is important to ensure that usage of a PRF is limited to only those patients at high risk, and only for the duration of the increased risk for suicide. The PRF is removed as soon as it is clinically indicated to do so. This is especially important to minimize the risk of undue stigmatization for the patient, and to maintain the value of the PRF system as an alert to an immediate clinical safety concern.

b) Carefully defined criteria for high risk for suicide are necessary to ensure that the PRF is appropriately used and maintains its clinical safety value. This determination needs to be made cautiously, and a record flagged only in the event that additional care should be taken by everyone interacting with the patient to attend to the increased risk for suicide. Reporting of suicidal thoughts or a call to the national suicide hotline alone is not an automatic indication of high risk.

c) Mental Health Safety Plans are still required to be completed within 30 days of a Veteran being flagged for high risk, regardless of their SRA rating.

6) All Veterans who are flagged for High Risk should have a completed Safety Plan (if they are agreeable) prior to being discharged from the inpatient mental health unit or within 30 days of being flagged.

I I

Policy Memorandum No. 122-19 March 15, 2017 j . When An Unexplained Death Occurs On Station:

1) No statement or assumption by the physician, nurse, or other official must be made regarding the apparent circumstances surrounding an unexplained death.

Beyond the rendering of life support procedures prior to the pronouncement of death, the body and all surrounding areas must be left absolutely untouched.

2) A death of violence or unexpected nature should be approached as an unexplained death and no more. Much damage may be done to the family, the patient's reputation, and the death investigation itself by premature labeling of the manner in which death may have occurred.

3) VA Police should immediately summon local police to begin an investigation.

The first VA Police officer arriving on the scene will be responsible for securing the area, ensuring the chain of custody is untainted and supplying needed protection.

4) The physician and other staff, shown in Figure 1 below, should be contacted re ardin the death.

Figure 1.

Cascade of Contacts to be Made in Event of Unexplained Death on Station

Unit/Clinic Manager

Manager I Supervisor

Regional Counsel

County Medical Examiner

Attending Physician or Primary Provider and Suicide Prevention

Coordinator

Patient Safety Manager

Decedent Affairs

Medical Center Director

Service Chief

Family

VA Police

Chief of Staff

Associate Director Associate

Director/Patient Care Services

5) The physician and RN should complete the ePER and the nurse manager/program manager completes an Issue Brief for leadership review as soon as possible.

k. Follow-Up With the Deceased Veteran's Family: Following the completed suicide of a Veteran patient who has been receiving treatment at this PVAHCS, the mental health or medical treatment team responsible for the patient's care will select a team member to contact the patient's family. This staff member will offer the condolences of all treating staff, and offer to provide short-term bereavement counseling and/or referral for such counseling in the community. A member of the Suicide Prevention Team will also contact the patient's family to offer condolences and assistance. The family will be provided information on the availability of VA resources for burial and funeral services by Decedent Affairs.

6. RESPONSIBILITIES:

a. The Medical Center Director has overall responsibility for implementing this policy.

b. ACOSs/Service Chiefs/Supervisors who manage inpatient units will assure a safe environment for any patients thought to be at risk for suicide. All Supervisors will assure that staff who may come in contact with suicidal patients have received adequate tra ining in the recognition and management of such patients.

c. All personnel are responsible for reporting any person in the PVAHCS who demonstrates suicidal behavior. When any person expresses suicidal behavior or threats, it will be reported to the charge nurse, physician, primary provider, other clinician in the area, the VA Police, and complete a Suicidal Behavioral Report. If the behavior appears to pose immediate danger, a Behavior Code should be called if necessary to assure patient/staff safety.

7. REFERENCES:

a. Department of Veterans Affairs (VHA). Directive 2010-053, Patient Record Flags, corrected copy 02/03/2011 .

b. Department of Veterans Affairs (VHA). Directive 1071 , Mandatory suicide risk and intervention training for VHA health care providers, dated June 27, 2014.

c. Department of Veterans Affairs (VHA). Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, amended November 16, 2015.

d. Department of Veterans Affairs (VHA). Memorandum, Suicide Awareness Training, dated June 25, 2008.

Policy Memorandum No. 122-19 March 15, 2017

e. The Joint Commission (T JC). (2016). National patient safety goals. Retrieved from http://www.jointcommission.org/standards information/npsgs.aspx

f. The Joint Commission (T JC). (2016). Sentinel Event Alert No. 56. Retrieved from https://www.jointcommission.org/assets/1/18/SEA 56 Suicide.pdf

g. PVAHCS Policy Memorandum No. 132-13, Management of Wandering and Missing Patients.

h. PVAHCS Policy Memorandum No. MH&BSS/116A-7, Processing Involuntary Psychiatric Patients.

i. PVAHCS Policy Memorandum No. 116A-08, Mental Health Crisis Evaluations.

8. RESCISSION: Policy Memorandum No. 122-19, Suicide and Suicide-Related Behaviors, dated November 15, 2014, is being revised to add additional clarification and procedure(s).

9. ATTACHMENTS: None

10. EXPIRATION DATE: March 2020

~~O~L~ Medical Center Director