FACILITY
SAMPLE POLICY AND PROCEDURE
SECTION: FACILITY
POLICY/PROCEDURE #: ____
SUBJECT: SUICIDE PREVENTION PLAN
FORM’S REFERENCE #:
REFERENCE/AUTHORITY: 42CFR483.25, F-319
POLICY REFERENCE #:
Suicide Prevention Guideline
PURPOSE
To provide guideline, safety measures and treatments to residents who present a suicide risk.
POLICY
Residents who are actively suicidal cannot be cared for at FACILITY.
Staff observing potential suicidal statements and behaviors exhibited by residents will report to
supervisory staff immediately and take measures to promote safety.
DEFINITIONS
Suicidal: Purposeful self-injury with the intention to kill oneself (suicidal behavior), or, verbalizing plan,
intent, and having the means to complete a suicidal act.
Suicidal Ideation (SI): Thoughts of being dead or of killing oneself. These would be noted in statements
or gestures by the person.
Passive Suicidal Ideation (thoughts and statements): talking of thinking about “being dead” or killing or
hurting yourself, but not really doing it. For example: “I wish I were dead. Sometimes I just want to kill
myself I feel so depressed.”
Active Suicidal Ideation: Thinking that killing or hurting yourself is a good idea and thinking of some
realistic ways you might do it. Example: “I want to kill myself by smothering myself with a garbage bag
and taking pills and I have been hiding pills to do this.”
PROCEDURE
1. Residents are screened prior to admission for suicidal ideation (SI) and potential for self harm by
physician and nurse reviewers. Residents who are actively suicidal are not admitted.
2. If a resident mentions suicidal ideation at any time, this is reported to physician, psychologist or
social worker to evaluate threat.
3. All staff members are obligated to report suicidal statements or other indicators of possible
suicidal ideation to their immediate supervisor.
4. Staff members who can conduct an assessment for suicide risk include licensed staff members
with specific training and experience conducting such assessments (RN, Physician, psychologist,
social worker).
5. If the resident is determined to be actively suicidal with the intent to harm themselves and the
ability to do so, they will be transferred to an acute care hospital or other appropriate higher level
of care (this may include heightened monitoring and/or placement on FACILITY’s secure
neighborhood or Close Watch neighborhood).
6. If the resident is actively suicidal, but with limited physical abilities to carry it out, can be
persuaded to agree not to kill themselves or who is passively suicidal, a plan of care is developed
with interdisciplinary coordination to reduce risk of self-harm and to restore feelings of wellbeing.
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SAMPLE POLICY AND PROCEDURE
SUICIDE PREVENTION PLAN GUIDELINE
BACKGROUND:
Given the absence of valid or reliable “evidence based” tools for the prediction of suicide risk, the
clinician should focus on determining whether the resident has:
1. Suicidal intent,
2. A viable plan, and
3. The means to carry out their intent and plan.
Due to the variety and complexity of factors related to suicide risk, consultation with clinical peers is
essential, and any doubt should be resolved on the side of protecting the resident.
1. Any time a resident indicates suicide ideation (SI) or has an increased probability of harming
himself or herself, a process will be initiated by the licensed nurse or social worker to:
A. Screen the resident to determine if he or she requires an immediate referral to an acute care
hospital or other appropriate higher level of care.
OR
B. To determine the steps necessary to appropriately supervise/manage the resident while at
FACILITY.
2. When a resident, in any way, indicates that he or she might be suicidal, clinical staff should
directly ask the resident “do you feel like hurting yourself? If answers are vague or unclear, then
follow-up questions can be asked.
3. The result of this questioning is reported to the physician or psychologist for further assessment
and initiation of additional safety measures, if appropriate.
4. Screening questions may include:
 Have you had thoughts of death or of killing yourself? If so, what were they?
 Are you currently thinking about killing yourself?
 What did (are) you think(ing) about doing to yourself?
 What are your thoughts on how, when, and where you would do this?
History and environmental indicators (may be assessed via record or by resident
observation/questioning):
 Have you attempted suicide in the past? If so, what did you do?
 Has a close friend or anyone in the family committed suicide?
 Have you, or anyone in your family ever been treated for depression, emotional illness or
substance abuse?
 Have you tried to hurt yourself? If so, how?
 Is the resident physically capable of engaging in a suicidal act? (Note: consider less overt
means like the resident initiating a fall or choking.)
 Does the resident have bruises, cuts or other physical signs of self-harm?
 Do caretakers, or other persons associated with the resident report current self-injurious
behaviors?
 Obtain past medical records and INSYS report of prior treatment, if the resident’s
behavior is of concern, if available.
 If the resident is unable or unwilling to verbally communicate the above, and has engaged
in self-injurious behavior, they should be monitored closely to observe behavior that may
indicate their intention.
5. All clinical professionals assessing the resident document in the record – the questions asked, the
answers received and their clinical assessment of the degree of dangerousness and the
interventions suggested.
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FACILITY
SAMPLE POLICY AND PROCEDURE
Based on the above, the resident will be classified as:
LEVEL of RISK
Level of Observation
High risk – The resident is expressing
Transported via ambulance to an
1) clear intent to engage in suicidal behavior,
appropriate acute care setting.
2) has formulated a plan that is imminent and
While waiting for transport, the
capable of resulting in self-harm or death, and
resident shall be monitored on a
3) that the plan can be implemented by the
visual or arms length monitoring.
resident given the means available and the
The rooms and surroundings of
resident’s own capabilities. Additionally, past or those residents on high level of
present suicidal or self-injurious behavior
precaution shall be modified to
should be considered to place the resident in the remove any items which have a
high risk category, even if items 1-3 appear to
high potential of causing harm.
be of lesser severity or concern.
Moderate risk – The resident is
1) ambivalent regarding their intent to engage in
suicidal behavior, OR,
2) has expresses a vague plan, or one that is not
imminent (e.g., “when I get out of here, I’ll
jump off a bridge or something”), OR,
3) has described a plan that the resident is
clearly incapable of implementing.
May be placed on visual, arms
length or frequent checks
monitoring, depending on what is
needed to insure the immediate
safety of the resident. Consider
move to secure neighborhood.
Of concern – The resident has made vague
statements like “sometimes I wish I wasn’t
here,” or, “I wish I just wouldn’t wake up
again.” Also, changes in the resident’s behavior
like their becoming more withdrawn, giving
away items, recent changes in medical status, or
hopeless/helpless statements should be grounds
for further assessment.
May be placed on frequent
checks, or staff should examine
other ways to increase their
supervision of the resident on the
unit. Increased supervision could
include asking the resident to
spend time in the dayroom or in
some other place where they are
more visible to staff. In addition,
environmental modifications may
be effected based on the clinical
assessment.
If residents with
high suicide risk
attempt to leave the
grounds, and are
still suicidal, law
enforcement is
notified.
 The level of risk shall be reported to the primary physician and documented in the medical record.
 Consultation with the physician or psychologist should be arranged as soon as possible to assist in
determination of the level of supervision and any environmental or care plan modifications which
might be needed.
 Heightened supervision and environmental modifications shall be made through interdisciplinary
collaboration based on the clinical assessment of the resident’s abilities and propensities and the
perceived risks and benefits of various interventions.
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FACILITY
SAMPLE POLICY AND PROCEDURE
ENVIRONMENTAL MODIFICATIONS
Any time a resident is deemed to be at risk of engaging in suicidal or self-injurious behavior, the
resident’s environment must be examined to remove items or modify conditions that could be used by the
resident to harm themselves. This includes, but is not limited to:
 Removal of sharp objects (e.g., scissors, knives nail files).
 Visitation may be limited.
 Access to windows or other glass items that could be broken to produce a sharp edge may be
restricted or require observation.
 Removal of belts, power cords, ties, shoelaces.
 Removal of plastic bags.
 Access to areas where staff cannot see the resident, or that can be locked to prevent entry may be
restricted.
 Access to chemicals, solvents or medications may be further restricted.
 Access to power wheelchair may be restricted.
 Leaving the unit while unsupervised may be prohibited (if the resident insists on this while being
monitored for SI, they should be considered at high risk, and referred to an appropriate acute care
setting for evaluation).
 The resident may be moved for increased observation and to minimize access to items that may
be unknown to staff.
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FACILITY
SAMPLE POLICY AND PROCEDURE
Suicide Assessment
Suicide Clues Observed
Express Concern: “I am concerned about______.” “Do
you feel like hurting or killing yourself?”
Determine level of risk – Do not promise to keep anything secret.
High Risk – The resident is expressing 1) clear intent to engage in
suicidal behavior, 2) has formulated a plan that is imminent and
capable of resulting in self-harm or death, and 3) that the plan can be
implemented by the resident given the means available and the
resident’s own capabilities.
Moderate Risk – The resident is 1) ambivalent regarding their intent
to engage in suicidal behavior, OR, 2) has expresses a vague plan, or
one that is not imminent (e.g., “when I get out of here, I’ll jump off a
bridge or something”), OR, 3) has describes a plan that the resident is
clearly incapable of implementing.
Of Concern – The resident has made vague statements like
“sometimes I wish I wasn’t here,” or, “I wish I just wouldn’t wake up
again.” Also, changes in the resident’s behavior like their becoming
more withdrawn, giving away items, recent changes in medical status,
or hopeless/helpless statements should be grounds for further
assessment.
Transport via ambulance to
acute care setting. Monitor
1:1 at “arms length.”
1:1 at “arms length” or
frequent checks. Notify
physician and psychologist.
Frequent checks monitoring
or increased supervision.
Notify physician and
psychologist.
Contact physician and consult with supervisor. In addition, contact
psychologist for further assessment.
Assess the resident’s environment and remove items or modify
conditions to insure safety.
Document what you observed and what you did in the medical record.
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