Case 2:90-cv-00520-KJM-DB Document 5993-1 Filed 11/05/18 Page 1 of 182

The Third Re-Audit and Update of Suicide Prevention Practices
in the Prisons of the California Department of
Corrections and Rehabilitation
Lindsay M. Hayes, M.S.
November 5, 2018
Executive Summary
I.

Introduction

This report is submitted as an update to this reviewer’s preceding report, “The Second
Re-Audit and Update of Suicide Prevention Practices in the Prisons of the California Department
of Corrections and Rehabilitation [CDCR]” (ECF No. 5672, filed September 7, 2017). The
preceding report covered this reviewer’s findings from a second re-audit of suicide prevention
practices at 23 selected CDCR prisons. The report recommended that prisons which chronically
struggled with their suicide prevention programs, as well as almost all prisons that contained
Mental Health Crisis Bed (MHCB) units, undergo continued re-inspection, and that the
defendants continue to work with the Special Master and Suicide Prevention Management
Workgroup (SPMW) on outstanding initiatives previously committed to by CDCR. On January
25, 2018, the Coleman court issued an order adopting the report in full (ECF No. 5762).
This report is the fourth on an audit of CDCR suicide prevention practices and covers this
reviewer’s recent re-audit at 23 selected CDCR prisons. The on-site re-audit began on May 23,
2017 and concluded on February 15, 2018. The details and methodology of the re-audit/review
process are discussed in Part II, below. Part III of this report contains a summary of this
reviewer’s findings during the re-audit, including a status update on defendants’ progress in
implementing prior recommendations as contained in this reviewer’s initial audit report and the
accompanying report by the Special Master (ECF No. 5258, filed January 14, 2015). Part IV is
this reviewer’s inspection and findings regarding defendants’ proposal to build temporary
unlicensed MHCB units at the California Institution for Women (CIW) and the R.J. Donovan
Correctional Facility (RJD). Part V covers this reviewer’s conclusion and recommendations.
Lastly, Appendix A presents a prison-by-prison discussion of this reviewer’s findings at each of
the 23 re-audited prisons, together with summaries of CDCR Suicide Case Reviews of the 29
inmate suicides in those prisons during 2017.1
Finally, it should be noted that CDCR, its management team (including statewide mental
health staff) and legal counsel, as well as local custody, medical, and mental health leadership at
each of the prison facilities assessed during 2017-2018, continued to demonstrate full
cooperation during this reviewer’s suicide prevention assessment process.

1

Although there was a total of 30 suicides within CDCR facilities during 2017, review of the inmate suicide that
occurred in the California Correctional Center (CCC) in October 2017 was not included in this report because the
CCC was not chosen for review during this most recent suicide prevention assessment.

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II.

Methodology

This reviewer’s selection of 23 CDCR prisons for on-site re-auditing was based on a
variety of reasons, including their operation of MHCB units, findings during previous audit(s)
that their suicide prevention practices were chronically problematic, having a significant
population of inmates on the Mental Health Services Delivery System (MHSDS) caseload,
and/or the facility experiencing multiple inmate suicides. As in the previous audits, this
reviewer’s re-audit consisted of a two-day on-site examination of suicide practices at each of the
prisons. There were two exceptions: California State Prison, Sacramento and California State
Prison, Los Angeles County each necessitated three-day on-site examinations. The 23 re-audited
prisons and the dates of their on-site assessments were:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.

California State Prison, Sacramento (CSP/Sac): May 23-25, 2017
Wasco State Prison (WSP): June 8-9, 2017
California Institution for Women (CIW): June 19-20, 2017
California Institution for Men (CIM): June 21-22, 2017
Kern Valley State Prison (KVSP): July 11-12, 2017
North Kern State Prison (NKSP): July 13-14, 2017
Richard J. Donovan Correctional Facility (RJD): July 25-26, 2017
California Health Care Facility (CHCF): August 8-9, 2017
Mule Creek State Prison (MCSP): August 10-11, 2017
California State Prison, Solano (CSP/Solano): August 23-24, 2017
California State Prison, Corcoran (CSP/Corcoran): October 10-11, 2017
California Substance Abuse Treatment Facility (CSATF): October 12-13,
2017
High Desert State Prison (HDSP): November 2-3, 2017
California State Prison, Los Angeles County (CSP/LAC): November 1315, 2017
California Correctional Institution (CCI): November 16-17, 2017
Deuel Vocational Institution (DVI): December 5-6, 2017
Central California Women’s Facility (CCWF): December 7-8, 2017
San Quentin State Prison (SQ): January 2-3, 2018
California Medical Facility (CMF): January 4-5, 2018
California Men’s Colony (CMC): January 16-17, 2018
Pleasant Valley State Prison (PVSP): February 6-7, 2018
Salinas Valley State Prison (SVSP): February 8-9, 2018
Pelican Bay State Prison (PBSP): February 14-15, 2018

At each site, this reviewer again examined the prison’s performance with the following
suicide prevention measurement tools:
•
•
•

Thoroughness and degree of privacy afforded during the intake screening
process
Psych Tech (PT) practices in restrictive housing units
MHCB practices, including verification of required observation of suicidal
patients
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•
•
•
•
•
•
•
•
•

Use of suicide-resistant, retrofitted cells for MHCB patients and new intake
inmates assigned to administrative segregation units
Use of alternative housing for inmates awaiting transfer to MHCBs
Suicide risk assessments for emergency mental health referrals and
admittance/discharge from a MHCB/alternative housing
Safety planning for suicidal inmates
Appropriate follow-up services provided by clinical and custody staff to
inmates discharged from a MHCB or alternative housing
Custody rounds in restrictive housing units
Emergency medical response equipment in housing units
Compliance with suicide prevention training
Review of meeting minutes of the local Suicide Prevention and Response
Focused Improvement Teams (SPRFITs)

All inmate suicides which occurred during the review period in the 23 audited facilities
were reviewed through examination of the inmates’ health care records via Electronic Unit
Health Records (eUHRs) or the Electronic Health Record System (EHRS), CDCR Suicide
Reports, and Quality Improvement Plans (QIPs).
In addition, this reviewer and several other members of the Coleman Special Master team
attended the CDCR Statewide Mental Health Program’s three-day Suicide Prevention Summit
from October 17-19, 2017, at which, this reviewer presented preliminary findings from this most
recent suicide prevention audit. On January 18, 2018, the Special Master held a SPMW meeting
with his experts, the parties, and CDCR management officials, to assist in effectuating
defendants’ implementation of the recommendations contained in this reviewer’s prior audit
reports.
Finally, pursuant to the Coleman court’s January 25, 2018 order adopting this reviewer’s
preceding report, defendants were ordered to “continue to implement the remaining
recommendations in the initial audit report and develop corrective action plans based upon
deficiencies found in Mr. Hayes’ most recent assessment.” (ECF No. 5762 at 4.) The Special
Master was directed to “provide an updated report to the court on the state of defendants’
continued implementation of the initial recommendations and the development of related
corrective action plans.” (Id.) In response, during Coleman All-Parties Workgroup
teleconference calls held by the Special Master on February 26, 2018 and April 9, 2018,
defendants provided updates on anticipated corrective actions for several suicide prevention
issues. On May 14, 2018, defendants provided this reviewer with an updated corrective action
plan (“May 2018 CAP”) for resolving suicide prevention deficiencies found in this reviewer’s
prior reports. Consistent with the court’s order, this report provides an update on current suicide
prevention practices within CDCR facilities and the status of current and anticipated corrective
actions to resolving existing deficiencies.
III.

Summary of Suicide Prevention Practices in CDCR Facilities

Although the current reassessment again found continued progress at varied speeds,
certain problematic practices continued to fester. Significant improvement was found in the
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areas of PT practices, use of alternative housing, and completion rates for annual suicide
prevention block training of custody personnel. In addition, all 23 audited facilities had
compliance rates of over 90 percent for custody checks in restrictive housing units via Guard
One, but these high compliance rates were tempered by the fact that four inmates who committed
suicide in restrictive housing units during 2017 were found to be in various states of rigor mortis
and not observed at 30-minute intervals as required. High rates of compliance were also found
in Cardiopulmonary Resuscitation (CPR)/Automated External Defibrillator (AED) training of
custody and medical staff.
In the areas related to initial health screening, use of suicide-resistant cells for newlyadmitted administrative segregation inmates, and completion of suicide risk assessments for
emergency mental health referrals related to suicide risk, there were varying degrees of progress.
The review found little improvement with safety planning and local SPRFIT practices.
Lingering problems regarding suicide-resistant MHCBs necessitated involvement by the court.
Results were also mixed within the areas related to clinically-ordered possessions and privileges
for MHCB patients, whereas significant problems remained related to five-day clinical follow-up
and custody welfare checks for patients discharged from MHCBs and alternative housing.
Finally, a new and systemic deficiency was found, the failure of nursing staff to adequately
observe suicidal patients in MHCBs at required 15-minute intervals in most of the audited
facilities.
The failure of nursing staff to adequately observe suicidal MHCB patients was
particularly concerning and, as indicated below, inadequate observation of these patients was
found in 18 of 21 or 86 percent of the audited facilities. This finding includes two facilities in
which this writer observed nursing staff falsifying observation forms. As the Coleman court
warned defendants when adopting this reviewer’s previous report on January 25, 2018 (ECF No.
5762), it was “deeply troubled” and “expects defendants will make clear to all staff that
falsification of information required by court order is unacceptable.” (ECF No. 5762 at 2-3).
The following provides (1) a brief summary of each of the main suicide prevention
measurement tools and their relationship to this reviewer’s original 29 recommendations,2 (2)
current findings related to CDCR’s adoption and implementation of the recommendations and
the reassessment of the 23 audited CDCR facilities, and (3) further recommendations for the
remedy of outstanding deficiencies.
A)

Initial Health Screening and Receiving and Release Unit Environment

Summary:
The original recommendations focused upon two areas of intake screening in receiving
and release (R&R) units: (1) the adequacy of the intake screening form and ensuring that all
questions were asked during the process, and (2) the adequacy of inmate privacy and
confidentiality during the process. The issue of intake screening form adequacy was related to
2

This reviewer subsequently recommended the withdrawal of three of the original 32 recommendations
(Recommendations 14, 15, and 16). (ECF No. 5672 at 7, 23.) The recommendation was adopted in the court’s
January 25, 2018 order (ECF No. 5762 at 3).

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the presence of certain compound questions on the form, as well as the thoroughness of form
completion by nursing staff. The issue of privacy and confidentiality was related to the practice
of the door to the nurse’s office remaining open during the screening process and/or officers
stationed inside the office or at the door.
Current Findings:
Although compound questions are no longer contained within the Intake Screening Form
embedded in the new EHRS, there has been mixed progress in resolving privacy and
confidentiality issues in the R&R units. In the preceding assessment, 18 of 23 or 78 percent of
audited facilities had adequate intake screening practices in their R&R units. During the current
assessment, previous problems found in five facilities (CIW, CSP/Corcoran, CSATF, KVSP and
PVSP) had mostly been resolved. However, issues of privacy and confidentiality remained at
one facility (CSP/Corcoran) and were found at three different facilities (CCI, CMC, and RJD),
while inadequate abbreviated screening practices were found at another facility (DVI). For
example, at CCI, there was no door to the nurse’s office and the desk where the newly-admitted
inmates were positioned was adjacent to a high-traffic area with other staff and inmates passing
through, creating both excessive noise and the absence of privacy and confidentiality. In the
other three facilities, the door to the nurse’s office remained open with an officer straddling the
doorway. At DVI, this reviewer observed a nurse failing to ask all of the mental health and
suicide risk questions during the intake screening process. When asked why all the questions
were not asked, this reviewer was informed by the nurse that an “abbreviated” screening was
completed if the county transfer form did not include any documentation of prior mental health
or suicide history. Such a response was problematic for several reasons: CDCR policy required
that all questions be asked; an individual could certainly become suicidal following their county
jail confinement and transfer to CDCR; and despite not asking all of the required questions, the
nurse entered “no” to all mental health and suicide risk responses in the EHRS for the screened
inmates observed by this reviewer. In sum, 18 of 23 or 78 percent of audited facilities had
adequate intake screening practices in their R&R units, the same level of compliance that was
found during the previous assessment.
Defendants’ May 2018 CAP indicated that a regional chief nursing executive (CNE)
meeting had been held to resolve the issue of inadequate privacy and confidentiality. The CNEs
were instructed to monitor compliance with the CAP. The status of the CAP was incorrectly
marked “completed.” This CAP item should have been marked as “ongoing” rather than
“completed” because there was no indication that any monitoring had been initiated to verify full
correction of the problem.
Recommendation:
Aside from the development of CAPs for the five facilities (CCI, CMC, CSP/Corcoran,
DVI, and RJD) referenced above, no further recommendations are offered related to this issue.
The issue should be monitored again by this reviewer during a proposed reassessment to ensure
that the defendants’ CAP has sufficiently resolved the deficiencies.

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B)

Psych Tech Practices

Summary:
According to the MHSDS Program Guide (Program Guide), PTs are required to conduct
daily rounds in all administrative segregation units and weekly rounds in Security Housing Units
(SHUs)/Psychiatric Services Units (PSUs) “to attend to the mental health needs of all inmates,
with documentation of their observations for each MHSDS inmate recorded on a Psych Tech
Daily Rounds Form.” This reviewer’s previous audits found inconsistent and problematic PT
rounding in these units, ranging from “drive-by” rounds with little interaction with caseload
inmates, to practices of PTs often completing the required forms following the completion of
rounds rather than immediately following each inmate encounter as required by policy.
Current Findings:
This reviewer’s current assessment found that all 23 audited facilities had adequate PT
rounding practices in their restrictive housing units (administrative segregation, SHU, and PSU).
PTs were consistently observed to be conversing with both MHSDS and non-MHSDS inmates,
and correctly entering the Psych Tech Daily Rounds information into the EHRS for each
caseload inmate.
Recommendation:
No recommendations are offered related to this issue.
C)

Suicide-Resistant MHCBs

Summary:
Previous audits found that, although most MHCBs were suicide-resistant, some were not.
Problems found in several MHCB units included rooms with square-shaped stainless-steel sinks
protruding from the wall which could be used as attachment points for a noose and thus were
conducive to suicide attempts by hanging. Other hazards included some rooms containing wall
ventilation grates with holes that were larger than the industry standard 3/16-inch diameter,
allowing for the possibility of being conducive to suicide attempts by hanging, as well as rooms
with small gaps between the wall and window frame. Previous recommendations to CDCR
included the development of a CAP for each facility that had hazards in its MHCB units.
Current Findings:
This reviewer’s current assessment found that 18 of 21 or 86 percent of the audited
facilities with MHCB units had suicide-resistant MHCBs. Problems at two facilities (CIM and
CSP/Corcoran) have been long-standing.

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First identified by this reviewer in 2013, all of the MHCB rooms at CIM continued to be
hazardous and were not suicide-resistant. In one wing, rooms had small gaps between the wall
and window frame, faucet handles, and ventilation grates with large holes in the ceiling
(although the ceilings were high and not within easy reach) that were conducive to suicide
attempts by hanging. In another wing, there were rooms with small gaps between the wall and
window frame, faucet handles, exposed toilet chase piping, and ventilation grates with large
holes in the ceiling that were conducive to suicide attempts by hanging. A patient attempted
suicide by hanging in one of the MHCB rooms on January 6, 2017. At CSP/Corcoran, when the
MHCB unit was temporarily closed for renovation in 2016, this reviewer inspected the unit and
found that some rooms had wall ventilation grates containing holes that were in excess of 3/16inch diameter, and there was not a pending work order to correct these hazards.
As a result of these long-standing MHCB safety concerns at CIM, the court ruled on
January 25, 2018 that “[t]he ongoing existence of these conditions is unacceptable. Good cause
appearing, defendants will be directed to provide to the Special Master and file with the court a
detailed plan for completion of all the necessary work at CIM.…” (ECF No. 5762 at 2.) On
February 23, 2018, defendants submitted a plan to the court which included the planned start
(March 5, 2018) and the planned completion (August 6, 2018) dates of the CIM renovation
project. Defendants have since filed monthly updates regarding the CIM project; as of the
August 15, 2018 update, the renovation project was slightly behind schedule with an anticipated
completion date now scheduled for September 21, 2018.
As a result of the MHCB safety concerns at CSP/Corcoran, the court’s January 25, 2018
order directed that “[w]ithin 14 days from the date of this order defendants shall show cause in
writing why the inadequate wall ventilation grates at CSP-Corcoran cannot be replaced within
six months.” (ECF No. 5762 at 4). On February 7, 2018, defendants submitted a plan to the
court which indicated that the project would be completed within six months. On February 22,
2018, defendants informed the Special Master that the 24-bed MHCB unit at CSP/Corcoran
would be temporarily closed and that the renovation would commence by March 19, 2018, with
estimated completion within three to four weeks. On April 24, 2018, defendants notified the
Special Master that the renovation project at CSP/Corcoran had been completed and that all
MHCB unit beds were reactivated on April 24, 2018.
Finally, during the recent PBSP assessment, this reviewer was able to conduct a thorough
inspection of each MHCB room due to a low census (i.e., one patient) at the time of the audit.
The inspection found a previously unidentified deficiency of wall and ceiling ventilation grates
in each room having holes that were greater than the industry standard of 3/16 inches wide. The
MHCB rooms were otherwise suicide-resistant.
Recommendation:
CDCR should develop a work order for replacement of the wall and ceiling ventilation
grates in the MHCB unit at PBSP.

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D)

Use of Suicide-Resistant Cells for Newly-Admitted Inmates in
Administrative Segregation Units

Summary:
Pursuant to CDCR policy, all inmates initially placed in administrative segregation in
single-cells are required to be placed in cells that have been retrofitted to be suicide-resistant for
the first 72 hours. This reviewer’s previous audits found several problems regarding the housing
of newly-admitted inmates in administrative segregation. Original recommendations offered to
address these deficiencies included ensuring there were a sufficient number of suicide-resistant
retrofitted cells to house newly-admitted inmates and enforcing existing policy requirements of
only housing newly-admitted inmates in retrofitted cells (and re-housing other inmates into other
cells).
Current Findings:
Although there has been both a reduction in the overall administrative segregation census
population statewide, as well as further retrofitting of additional new intake cells, this reviewer’s
preceding assessment found that only 15 of 23 or 65 percent of the audited facilities had
adequate practices regarding the placement of newly-admitted administrative segregation
inmates in new intake cells. Problems continued during this most recent audit when only 13 of
23 or 57 percent of the audited facilities were found to have adequate practices. Problems found
in ten facilities (CIM, CMF, CMC, CSATF, DVI, HDSP, KVSP, PVSP, SVSP, and WSP)
included new intake inmates housed in unsafe, non-intake single cells during the first 72 hours of
administrative segregation confinement. In most cases, inmates were placed in an unsafe cell
because all new intake cells were occupied; in other cases, new intake cells were available, but
custody staff had not appropriately relocated the inmates. In two facilities (WSP and DVI), cells
identified for new intake inmates were not completely suicide-resistant.
The issue was particularly acute at DVI. The facility’s administrative segregation unit
housed general population (GP), 3CMS, and Enhanced Outpatient Program (EOP) inmates. The
unit originally had five retrofitted new intake cells, but that number had been increased to 11 in
the past year. However, the 11 new intake cells were not completely suicide-resistant. One cell
had a gap between the bunk and wall, and all 11 cells had ventilation grates with holes in excess
of 3/16-inch in diameter. In addition to these new intake cells not being completely suicideresistant, this reviewer observed three new intake inmates in unsafe non-intake cells. This
finding was problematic because two inmates who committed suicide in DVI’s administrative
segregation unit in October and November 2017 were not placed in suicide-resistant new intake
cells upon admission as required. At another facility (CSP/LAC), a new intake inmate
committed suicide in an unsafe non-intake cell in the EOP administrative segregation unit in
August 2017 even though a suicide-resistant new intake cell was available for use at the time of
admission.

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Defendants’ May 2018 CAP indicated that CDCR was in the process of developing a
“methodology for determining appropriate number of intake cells [due March 2018]…Report in
development to determine which cells intake inmates are placed in time frame [due September
2018].” The status of this CAP item was marked “in process.”
Finally, a previous issue of administrative segregation cells in two facilities (CSP/Solano
and WSP) containing frosted exterior window glazing that reduced natural light was resolved
when CDCR’s Division of Adult Institutions (DAI) decided that “safety and security reasons”
prohibited the removal of the glazing material, and that MHSDS inmates would not be housed in
administrative segregation cells that contained the glazing material.
Recommendation:
Similar to the previous assessment, CDCR should develop CAPs in each of the ten
facilities identified above to ensure that newly-arrived administrative segregation inmates
assigned to single cells are placed in new intake cells for the first 72 hours of administrative
segregation confinement. Some of the CAPs may involve creating additional retrofitted new
intake cells, ensuring that all currently identified new intake cells are suicide-resistant, and
reinforcing the requirement that new intake inmates should not be placed in non-new intake cells
when new intake cells are available.
E)

Use of “Alternative Housing” for Suicidal Inmates

Summary:
According to the Program Guide, an inmate who meets the criteria for MHCB placement
is required to be transferred to a crisis bed within 24 hours of referral. In the interim, as well as
in those cases in which physical transfer does not occur within that time frame, the inmate is
required to be placed in “alternative housing.” The most recent policy enacted following
issuance of the Program Guide relevant to alternative housing is Policy 12.05.301 (“Housing of
Patients Pending Mental Health Crisis Bed Transfer”), revised October 15, 2015. The policy
listed the following preferred locations for housing suicidal inmates pending transfer to an
MHCB: Correctional Treatment Center (CTC) licensed medical beds; Outpatient Housing Unit
(OHU); OHU overflow cells; Large holding cells with toilets; Large holding cells without toilets;
Triage and Treatment Area (TTA) or other clinic physical exam room; Other unit-housing where
complete and constant visibility can be maintained; and CTC holding cells.
This reviewer’s previous assessments found that suicidal inmates placed in alternative
housing were often placed in hazardous, unsafe cells and observed at intervals that varied
between constant observation and 15-minute intervals. In addition, many suicidal inmates were
housed in these locations for more than 24 hours and oftentimes not provided a bunk, instead
having to sleep on a mattress on the floor thus increasing the possibility that an otherwise
suicidal inmate would deny their suicidal ideation to avoid continued perceived punitive
conditions. As a result, previous recommendations by this reviewer focused on requirements for
suicide-resistant alternative housing and/or constant observation of inmates placed in hazardous,

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unsafe alternative housing locations, as well as issuance of suicide-resistant bunks for any inmate
housed in alternative housing for more than 24 hours.
Defendants agreed to implement the above recommendations and issued various
directives indicating that all suicidal patients placed in alternative housing would be placed on
continuous 1:1 observation until they were transferred to a MHCB, as well as provided portable
suicide-resistant beds (referred to as “stack-a-bunks”) in those locations that did not already have
available bunks.
Current Findings:
With the exception of alternative housing lengths of stay in four facilities greatly
exceeding 24 hours, previous deficiencies in this area have been corrected. This reviewer’s
preceding assessment found that 14 of 23 or only 61 percent of the audited facilities had
adequate practices regarding the use of alternative housing for suicidal patients referred for
MHCB placement. Significant problems found in nine facilities included use of Board of Parole
Hearings (BPH) cells, some of which were dry cells (i.e., without sinks and toilets), as well as
dry holding tanks and holding cages. All of these housing locations had no access or limited
access to bunks, showers, and bathrooms.
During the most recent assessment, this reviewer did not observe any alternative housing
inmates placed in BPH cells or any dry cells in the 23 audited facilities. In addition, the
assessment found that most alternative housing placements occurred in either CTC licensed
medical beds, GP housing unit cells, administrative segregation unit cells, TTA holding cells, or
OHU cells. Inmates in alternative housing were provided beds and required to be observed on a
continuous 1:1 basis (except in CMC where all cells were suicide-resistant because the location
had been previously utilized as an unlicensed MHCB unit and inmates were required to be
observed at 15-minute intervals).
Finally, the most recent assessment found that 18 of 22 or 82 percent of the audited
facilities housed inmates in alternative housing for 24 hours or less, with nine facilities having an
average length of stay of 16 hours or less. However, four facilities had average lengths of stay
that far exceeded 24 hours: CIW at 67 hours, CCWF at 51 hours, RJD at 50 hours, and
CSP/Corcoran at 35 hours. The overall length of stay in alternative housing for inmates in the 22
audited facilities was 23 hours.3 This was a marked improvement from prior assessments which
found a significant percentage of inmates placed in alternative housing well in excess of 24
hours.
Recommendation:
CDCR should develop CAPs in each of the four facilities (CIW, CCWF, CSP/Corcoran,
and RJD) that continue to have alternative housing lengths of stay well in excess of 24 hours. In
3

The overall average length of stay in alternative housing at CIM could not be calculated due to the unreliability of
the reviewed data. As detailed later in this report, this reviewer examined several cases in which data indicated that
inmates were held in alternative housing for “zero” time whereas observation sheets examined indicated that the
inmates were actually held for 26 to 28 hours.

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addition, a CAP should be developed at CIM to ensure the correct calculation of length of stay
data in alternative housing of that facility.
F)

Practices for Observing MHCB Patients

Summary:
Previous assessments by this reviewer found that, despite clear Program Guide
requirements for two levels of observation (i.e., Suicide Watch requiring continuous 1:1
observation and Suicide Precaution requiring observation at staggered 15-minute intervals),
some suicidal patients were being observed in MHCB units at 30- and 60-minute intervals under
observational terms such as “psychiatric observation” or “crisis evaluation.” In addition,
inadequate practices were found in the timely completion of required “Suicide Watch/Suicide
Precaution Record” observation forms by nursing staff, including the falsification of observation
forms for patients on Suicide Precaution status. Recommendations were provided for CDCR to
enforce Program Guide requirements utilizing only two levels of observation, to provide better
guidance and consistent guidelines regarding an acceptable level of observation for non-suicidal
patients housed in MHCB units, and to develop a process by which the observation of suicidal
MHCB patients was audited on a regular basis.
Current Findings:
On March 15, 2016, CDCR issued a memorandum entitled “Level of Observation and
Property for Patients in Mental Health Crisis Beds” requiring that for those MHCB patients who
did not meet criteria for either Suicide Watch or Suicide Precaution, or who were no longer
suicidal, orders were “not to be written for a frequency of more than twice an hour (30
minutes),” and that vague terms such as “psychiatric observation” or “behavioral observation”
were not permitted. A more recent memorandum dated April 18, 2018 entitled “Reminder:
Level of Observation for Patients in Mental Health Crisis Beds” specified that orders for
observation of non-suicidal MHCB patients “shall not be written for a frequency less often than
permitted by the program’s licensing requirements.”
This reviewer’s most recent assessment found that observation levels of non-suicidal
patients housed within all 21 facilities containing an MHCB unit were set at either 15- or 30minute intervals. In addition, vague terms such as “psychiatric observation” or “behavioral
observation” had been eliminated from most local operating procedures at these facilities.
However, the problem of non-compliance with required observation of suicidal patients
had not been resolved and, in fact, had been exacerbated. CDCR’s new EHRS easily allows for
accurate verification of nursing rounds performed within MHCB units because the observation is
recorded in real time when entered by the user and cannot be altered. During this assessment
period, 16 facilities with MHCB units had implemented EHRS. At the remaining five facilities
with MHCB units, nursing staff were still utilizing hard-copy Suicide Watch/Suicide Precaution
Record forms to document the observation of patients on suicide observation status. As such,
accuracy of observation rounds in non-EHRS facilities could only be verified through on-site
observation of nursing rounds.
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While on-site at the 16 facilities utilizing the EHRS, this reviewer was able to verify the
accuracy of observation rounds of patients on Suicide Precaution status (and requiring
observation at staggered 15-minute intervals) by reviewing each patient’s EHRS chart.
Typically, four patient charts were selected at each facility for nine-hour periods ranging from
12:00 a.m. through 8:59 a.m. The findings were problematic, with violations found in all 16
facilities—attributable to multiple nursing personnel during multiple days at each facility.
Although three facilities (CMC, CSATF, and CSP/Sac) were found to have only minor problems,
with chart reviews finding only a few observation checks (e.g., two or three per patient) that
were in excess of required 15-minute intervals, with the longest gap between checks typically
being less than 30 minutes—the remaining 13 facilities had significant problems. Many facilities
typically had between ten and 14 observation checks that were in excess of the required 15minute intervals during a nine-hour period. Some of the worst practices were found at
CSP/LAC. The chart review found numerous observation checks (between eight and nine per
patient) that were in excess of required 15-minute intervals in two of the four cases, with the
longest gap between checks being 28 minutes. The violations in the other two cases were
alarming. In one case, there were multiple time gaps including two and three hours (from 12:12
a.m. to 2:05 a.m. and then from 2:07 a.m. until 5:38 a.m. on one date). In the other case, there
were multiple time gaps that included a five-hour period (12:19 a.m. until 5:28 a.m.) on one date.
Later that morning, the patient was observed with a piece of cloth tied around his neck and had
been last observed 24 minutes earlier.
In addition, this reviewer observed the falsification of observation forms in two (CIM and
MCSP) of the five facilities that had not yet implemented EHRS. In sum, the most recent
assessment found inadequate observation of suicidal MHCB patients in 18 of 21 or 86 percent
of the audited facilities.4 Possible explanations for these systemic deficiencies include an
inadequate number of nursing staff assigned to conduct observation rounds, inadequate number
of laptop or desktop equipment to record observation rounds on a timely basis, inadequate
training of nursing staff (with some believing that documentation could be recorded at a later
time), and simply neglectful practices.
Defendants’ May 2018 CAP indicated that “EHRS modification to trigger tasking of MH
observation orders was built. This will trigger staggered rounding and allow determination of at
what point the task was completed (real time). Training via webinar was conducted [in February
2018]. CQIT contains indicators to assess if rounding was staggered and if documentation
occurred in real time. Regional mental health teams will audit to ensure entries are completed in
real time by comparing task time and documentation time. CNA training on conducting suicide
watch and suicide precaution.” The status of this CAP item was marked “in process.”

Recommendation:

4

The 18 facilities were CCWF, CHCF, CIM, CIW, CMF, CMC, CSATF, CSP/LAC, CSP/Solano, CSP/Sac, HDSP,
KVSP, MCSP, NKSP, PBSP, PVSP, SQ, and SVSP.

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Deficiencies surrounding the observation of suicidal MHCB patients is both acute and
potentially dangerous. In addition to Continuous Quality Improvement (CQI) and regional
mental health team audits, nursing supervisors at each facility containing a MHCB unit should
conduct regular EHRS audits to ensure that suicidal patients are being consistently observed as
required. The issue should be monitored again by this reviewer during a proposed reassessment
to ensure that the CAP has sufficiently resolved the deficiencies.
G)

MHCB Practices for Possessions and Privileges

Summary:
Previous assessments by this reviewer found disparate practices with regard to privileges
provided to medical versus mental health patients within CTCs. Whereas patients admitted into
a CTC for medical purposes were generally eligible for recreation, visits, or telephone calls, such
privileges were generally prohibited for MHCB patients. Recommendations were provided for
CDCR to develop a directive(s) regarding guidance on clothing and allowable privileges for both
suicidal and non-suicidal MHCB patients.
CDCR subsequently issued several memoranda to address the issue. One such
memorandum, “Level of Observation and Property for Patients in Mental Health Crisis Beds”
was issued on March 15, 2016. The directive required that “all orders shall detail what specific
items may be issued to a patient. Staff shall ensure all patients are provided with the clothing,
bedding and allowable items permitted at the patient’s level of observation.”
On June 23, 2016, CDCR issued a memorandum on MHCB privileges available to
MHCB patients entitled “Mental Health Crisis Bed Privileges.” The directive stated that “IPs
admitted to the MHCB may be authorized for out-of-cell activities when specifically approved
by the MHCB IDTT.” Out-of-cell activities included, but were not limited to, dayroom,
recreational activities, and yard. These activities would be the responsibility of the recreation
therapist (RT) assigned to each MHCB unit, and “custody staff may provide supervision for
unstructured out-of-cell activity to include yard in dayroom.” In addition, the memorandum
stated that MHCB patients were entitled to both telephone access and visiting privileges “unless
specifically restricted by the MHCB IDTT.” In late 2016, the memorandum was revised on
several occasions to strengthen authorizing language. The final version of the “Mental Health
Crisis Bed Privileges” memorandum was issued on February 14, 2017. The memorandum
reiterated that “the recreational therapist shall be responsible for facilitating all structured out-ofcell activity and is expected to remain with the IP during these activities.”
Current Findings:
Although there has been improvement since the 2016 audit when only three of 21 or 14
percent of the audited facilities with MHCB units had adequate practices with regard to the
issuance of clothing and privileges for patients, problems remained at many facilities. During
the most recent assessment, this reviewer found that only 12 of 21 or 57 percent of facilities with
MHCB units had adequate practices regarding the issuance of clothing and privileges for
patients. Practices at the remaining nine facilities (CIM, CMF, CSP/Corcoran, CSATF,
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CSP/Sac, CSP/Solano, PVSP, SVSP, and WSP) were problematic. For example, at WSP,
MHCB patients were not consistently receiving out-of-cell activities, including telephone calls
and visits. In fact, a local operating procedure (LOP) at the facility still indicated that MHCB
patients on either Suicide Watch or Suicide Precaution status were not eligible for yard activities.
In addition, there was a shortage of RT personnel at the facility, resulting in few opportunities for
out-of-cell activities. Although an RT at WSP informed this reviewer that MHCB patients
received 30 minutes out of their rooms a few times each week in the yard or the program office,
a records review suggested otherwise. The records indicated that patients were given the option
of either receiving yard or program office privileges, but not both. In fact, most patients were
not even given the option of recreating in the program office, rather the RT interacted with them
cell-side. There was little use of the yard. In sum, except for the periodic opportunity to shower,
this reviewer found that MHCB patients at WSP spent an inordinate amount of time confined in
their rooms.
At CSP/Solano, there were multiple deficiencies found, including (1) a significant
shortage of RT availability resulting in limited interaction with MHCB patients, (2) lack of a
program room resulting in RT programming limited to board games either cell-side or in the
therapeutic treatment module; (3) records indicated that none of nine patients had been offered
yard consistent with CTC policy, there was documentation for only three of the patients being
offered yard during their entire MHCB placement, and records indicated that no patients had
been out into the yard during a recent four-day period; (4) custody staff reported that telephone
and visiting privileges rarely occurred in the MHCB unit; (5) only four of nine patients had been
offered showers consistent with policy; and (6) a patient not on suicide observation status and
clinically ordered to receive “full-issue” clothing (shirt/pants or jumpsuit) observed wearing only
a T-shirt, boxers, and a smock.
At CSP/Corcoran, there were also multiple deficiencies found, including (1) no patients
on full-issue clothing status were issued either a uniform or shirt/pants because such clothing was
not available in the MHCB unit, with this reviewer being informed by interdisciplinary treatment
team (IDTT) members that safety smocks were issued to each patient for “privacy”; (2) multiple
contradictory and/or incorrect orders that allowed for both issuance of a safety smock and
“partial-issue” (i.e., shorts and t-shirt), orders to disallow both yard and telephone privileges
without clinical justification for patients not on suicide observation status, and orders that
incorrectly automatically denied yard privileges for patients on administrative segregation status;
(3) limited RT availability resulting in patients only seen for approximately one hour every three
days, and patients approved for out-of-room activities being forced to choose between the
program office or yard; and (4) only approximately one third of MHCB patients approved for
yard (with no administrative segregation patients ever approved), and non-administrative
segregation patients not approved for telephone privileges.
Defendants’ May 2018 CAP did not contain any proposed remedies to correct these
deficiencies. However, during the SPMW meeting on January 18, 2018 and the Coleman AllParties Workgroup teleconference on April 9, 2018, CDCR officials suggested that a webinar
would be held for MHCB clinicians to reiterate the requirement for granting possessions and
privileges to MHCB based upon clinical judgment, and that consideration would be given to
again reissuing the “Mental Health Crisis Bed Privileges” memoranda. Defendants also
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acknowledged that a shortage of RT personnel adversely affected the provision of out-of-cell
activities even when ordered by the IDTT.
Although the final version of the “Mental Health Crisis Bed Privileges” memorandum
issued on February 14, 2017 requires that “the recreational therapist shall be responsible for
facilitating all structured out-of-cell activity and is expected to remain with the IP during these
activities,” this reviewer remains concerned about full patient access to out-of-cell activity in
MHCB units with inadequate RT staffing. Further, although CDCR previously contended that
“custody staff may provide supervision for unstructured out-of-cell activity to include yard and
dayroom” in the absence of the RT, this reviewer continued to find this option was not
consistently used during the most recent audits. Finally, given the frequent turnover of MHCB
clinical personnel, this reviewer is also not convinced that re-training of such personnel through
a webinar will adequately address the issue.
Recommendation:
MHCB supervisors in each of the nine facilities identified above should audit the
possessions and privileges clinically-ordered to MHCB patients and report findings to the local
SPRFIT committee until the issue is resolved. It is also recommended that CDCR develop a
CAP for recruiting a sufficient number of RT staff that can be assigned to MHCB units or, in the
interim, find additional non-RT staff to provide such services. Finally, the issue should be
monitored again by this reviewer during a proposed reassessment to ensure that the issue has
been resolved.
H)

30-Minute Welfare Checks in Administrative Segregation, SHUs,
PSUs, and Condemned Units

Summary:
CDCR’s requirement that inmates housed in administrative segregation be observed at
30-minute intervals has been in place since 2006, with inmates housed in SHUs requiring the
same level of observation since 2013. Documentation was historically recorded by handwritten
housing logs. In 2014, CDCR implemented the Guard One system to electronically verify 30minute welfare checks of all inmates in administrative segregation during the first 21 days of
their stays. Via a memorandum issued on May 9, 2014, the policy was subsequently revised to
extend use of the Guard One system to all inmates in administrative segregation units, SHUs,
PSUs, and condemned units at staggered intervals not to exceed 35 minutes for the duration of
their stays. This expansion was a significant and commendable policy change. Due to unique
architectural features of the SHU at PBSP and complaints of excessive noise generated from
Guard One, particularly during First Watch (10:00 p.m. to 6:00 a.m.), the parties agreed to a
permanent policy specific to the SHU at PBSP allowing for Guard One observation at 60-minute
intervals during First Watch. The permanent stipulation was approved by the Coleman court on
September 1, 2016 (ECF No. 5487).
Current Findings:

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This reviewer’s most recent assessment found all 23 audited facilities had Guard One
compliance rates of 90 percent or higher in administrative segregation, SHUs, and PSUs. This
was an improvement from the preceding assessment which found four facilities with Guard One
compliance below 90 percent. This high rate of compliance in all audited facilities was tempered
by the fact that three facilities (CSP/Sac, CSP/LAC, and PBSP) experienced four inmate suicides
in PSU and administrative segregation units during 2017 in which each decedent was found in
rigor mortis despite completion of a timely Guard One check, indications that correctional staff
did not adequately observe the interior of the cell to verify “a living, breathing inmate” as
required by policy.
Recommendation:
No recommendations are offered related to this issue. Correctional officers are already
trained in the current CDCR policy requirement to verify “a living, breathing inmate” during
each Guard One round. In addition, violations of the policy found during a CDCR investigation
of an inmate suicide results in a recommendation for a Quality Improvement Plan (QIP) during
the Suicide Case Review process.
I)

Suicide Risk Evaluations

Summary:
This reviewer’s previous assessments found that, although all emergency mental health
referrals for reported suicide ideation (SI) and self-injurious behavior (SIB) resulted in an almost
immediate response from mental health clinicians, these emergency referrals did not always
result in completion of the required suicide risk evaluations (SREs) or Suicide Risk and SelfHarm Evaluation (SRASHE).5 In addition, the quality of completed SREs was problematic.
Previous recommendations included revision of the SRE mentoring program and better auditing
of SRE quality on a monthly basis by local SPRFIT committees. Defendants previously agreed
with this reviewer’s assessments that the quality of completed SREs throughout CDCR was
problematic and agreed to issue the “Revision to the Suicide Risk Evaluation Mentoring
Program” memorandum, last revised on March 10, 2016, and the “Clarification of Suicide Risk
Evaluation Training Requirements” memorandum, last revised on March 24, 2016. The
memoranda included requirements for seven-hour SRE training every two years by clinical staff,
and annual training for clinicians regularly assigned to a MHCB unit, and the auditing of at least
one of a clinician’s SREs every six months.
Current Findings:
This reviewer’s most recent assessment found improvement in both the degrees of
compliance with seven-hour SRE training and mentoring programs, as well as the completion of
SREs and SRASHEs following an emergency mental health referral. The review found that 21
of 23 or 91 percent of audited facilities had compliance rates at 90 percent or more for either or
both the seven-hour SRE training and the mentoring programs, including nine facilities having
compliance rates above 90 percent for both programs. Only two facilities (CSP/Corcoran and
5

Of note, Suicide Risk and Self-Harm Evaluations (SRASHEs) have replaced SREs in the new EHRS.

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CMF) had compliance rates below 90 percent for both training programs, an improvement from
the preceding assessment when eight facilities were found to have compliance rates below 90
percent. For the current assessment, the overall rate of compliance for seven-hour SRE training
in the 23 audited facilities was 90 percent, whereas the compliance rate for the SRE mentoring
program in the same facilities was 85 percent.
In addition, 17 of 23 or 74 percent of the audited facilities had required SRE/SRASHEs
completed for emergency mental health referrals for SI and SIB in 90 percent or more of
sampled cases. In those six facilities (CMF, DVI, KVSP, CSP/LAC, NKSP, and PVSP) below
90 percent, compliance rates ranged from 76 to 85 percent. These findings are an improvement
from the preceding assessment when only 11 of 23 or 48 percent of the audited facilities had
completed SREs in 90 percent or more of the cases. With that said, however, completion of
suicide risk assessments for inmates presenting as possible risks for suicide should be automatic,
with compliance rates near or at 100 percent throughout CDCR—yet this issue continues to be
problematic.
Defendants’ May 2018 CAP stated that “[t]raining compliance is now provided to HQ by
the institutions and reviewed monthly in SPRFIT. Institutions [that] consistently are not in
compliance or [that] demonstrate downward trends will be required to develop CAPs in
conjunction with the regional teams.” With regard to completion of SRE/SRASHEs for
emergency mental health referrals involving SI and SIB, the CAP stated that “SRE [t]imeliness
is now reviewed monthly in SPRFIT. Institutions [that] consistently are not in compliance or
demonstrate downward trends will be required to develop CAPs in conjunction with the regional
teams.” The status of these CAPs was marked ongoing.
Recommendation:
Develop CAPs for the six facilities outlined above that continue to struggle with
completion of required SRE/SRASHEs for emergency mental health referrals involving SI and
SIB. The issue should be monitored again by this reviewer during a proposed reassessment to
ensure that the CAPs have sufficiently resolved the deficiencies.
J)

Safety Planning for Suicidal Inmates

Summary:
This reviewer’s previous assessments found that safety planning to reduce a MHCB
patient’s suicide risk was inconsistently observed during IDTT meetings, and the vast majority of
treatment plans developed by MHCB clinicians for suicidal patients were grossly inadequate and
often simply repeated Program Guide requirements (e.g., “discharge from MHCB, provide 5Day Follow-Up by Primary Clinician (PC), provide daily rounds by the PT, and medication
management”), rather than a specific plan to reduce the inmate’s suicide risk. In addition, there
was little concordance between safety planning strategies developed within the SRE/SRASHEs
that justified the discharge from a MHCB unit and subsequent five-day follow-up progress notes
written by clinicians to indicate that safety plan objectives were being addressed. Initial previous

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recommendations included additional “safety planning” training for clinicians which became
mandatory in 2016.
When this reviewer’s preceding assessment found continuing, and even worsening,
problems with adequate treatment planning, it was recommended that CDCR develop a process
by which each safety plan contained within the discharging SRE/SRASHE of a patient released
from a MHCB was reviewed by an SRE mentor at that facility. Without interfering with the
physical and administrative discharge of the patient from the MHCB, any safety plan found to be
deficient (i.e., not containing a reasonably specific strategy to reduce SI) should immediately be
returned to the authoring clinician for revision.
Finally, during a presentation to CDCR’s Suicide Prevention Summit held on October 18,
2017, this reviewer offered examples of both inadequate and adequate safety planning. An
inadequate safety plan was narrative that: (1) simply recited Program Guide requirements, (2)
recommended specific groups which were not available at the facility, (3) simply instructed the
patient to report any future suicidal ideation to CDCR staff, and (4) simply deferred the safety
plan to the transferring clinician. In contrast, an adequate safety plan: (1) addressed modifiable
risk and protective factors and warning signs, (2) flowed directly from assessed level of care, (3)
was specific and individualized, and (4) could be seen in five-day follow-up progress notes and
subsequent notes of the transferring clinician.
Current Findings:
This reviewer’s most recent assessment found continuing problems with adequate safety
planning for SI in 20 of 21 or 95 percent of audited facilities with MHCB units. The only facility
demonstrating consistently adequate safety planning was RJD. One example of such safety
planning at RJD was the following:
D/C to EOP LOC. Start MH 5-day follow-up procedures. Add up to 10+ hours
of groups including life skills, conflict resolution and stress management. Add to
high risk list for at least 14 days to monitor for transition to ASU and to EOP.
Teach IP warning signs of stress (emotional, physical and psychological), as well
as coping skills for stress, including breathing techniques/meditation, mindful
drawing, encourage singing, puzzles for distraction, SMART goal setting, and
techniques to manage worrying (such as create a ‘worry’ period). Teach coping
skills to reduce impulsivity to reduce future 115s such as counting, breathing or
distraction. Teach DBT distress tolerance skills to reduce possible distress from
receiving 115, such as positive self-talk, engaging in activities, or prayer.
Monitor and encourage regular contact with family/support system. Inmate has
already been referred and accepted to DSH-ICF for further support.
The challenge at RJD (as well as at other audited facilities) was that, although clinicians
demonstrated adequate safety planning, there were often problems with concordance between
safety plans contained within discharging SRE/SRASHEs and safety plan summary sections
contained within accompanying Interdisciplinary Progress Note – 5-Day Follow-Up (CDCR

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MH-7230-B) forms. For example, the safety plan contained on the first day of the 5-Day
Follow-Up Progress Note for the above case stated the following:
MH staff will continue 4 more days of follow-up, or more, as needed. His dx now
is adjustment DO with depressed mood. He has no rx’d psychotropic meds now,
that several rx’d medical meds. He will continue taking them as rx’d and ask for
meds’ eval as needed. He will be monitored by CO staff hourly while in Ad Seg.
He will get and use a pencil and puzzles as distractions from his reported
boredom. He will ask for additional help as needed. He knows how to do so.
Although pockets of adequate safety planning by individual clinicians continued to be
found in the other 20 audited facilities throughout the CDCR system, none of these facilities
other than RJD demonstrated consistent safety planning. Continued examples of poor safety
planning included simply repeating Program Guide requirements, deferring the development of a
specific safety plan to the outpatient clinician rather than the MHCB clinician developing a
safety plan with the patient during their MHCB placement, and creating non-individualized
safety plans by cutting and pasting the same narrative for multiple patients. For example, at
WSP, one MHCB clinician simply wrote a narrative in several safety plans that the patients
“should identify at least 5 coping skills to decrease depression, anxiety, and impulsivity, promote
successful prison incarceration with decreased ability of self-injurious behavior, identify at least
3 goals for his incarceration,” thereby deferring the identification of appropriate coping skills to
other clinicians.
At CSP/Corcoran, a MHCB clinician wrote the following in the safety plan section of the
discharging SRASHE:
I/P is already on a 5-day f/u and to continue daily PC contact to address s/s and
monitor SI/HI.
1) Psychiatrist will prescribe and adjust medication as needed.
2) PC provide patient with Bible to read while in his cell.
3) PC will teach IP stress management and relaxation techniques to help decrease
stress and anxiety that seem to be increasing SI.
In addition, the first day of the patient’s Interdisciplinary Progress Note – 5-Day Follow-Up
(CDCR MH-7230-B) form stated the following under safety plan: “If sxs increase, IP to contact
staff/mental health staff immediately. Continue with current tx. plan.”
At HDSP, a MHCB clinician wrote the following in the safety plan section of the
discharging SRASHE: “His prior safety plan/treatment plan focused on stabilizing his mood,
developing goals for the future, and developing alternative strategies for relief besides cutting
(self-harm). The Pt currently states a safety plan is adequate for keeping him safe.” Such
narrative failed to identify the specific “goals” and “strategies” contained within either the
current or previous safety plan that was effective for the patient.
All of the above described examples were deficient because, contrary to CDCR’s safety
planning training, these safety plans did not (1) address modifiable risk and protective factors
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and warning signs, (2) flow directly from assessed level of care, and (3) were not specific and
individualized.
Further, this reviewer’s most recent assessment also included observation of IDTT
meetings within MHCB units. Although most meetings were found to be well-attended by
mental health, medical, and custody staff, discussion regarding safety planning was often
disjointed or non-existent. In one example from PVSP, the patient had been admitted into the
MHCB for suicidal ideation with a plan (“to use razors to cut his wrist”). His diagnosis was
Bipolar Disorder with depressed mood. The patient had stopped taking his psychotropic
medication a few months earlier which resulted in increased depression and suicidal ideation.
He was at the 3CMS level of care and had a previous MHCB admission during 2017. According
to a recently completed SRASHE, the patient was assessed as having both a “moderate” chronic
and acute risk for suicide based on risk factors that included a prior suicide attempt, family
history of suicide, increased depression, and on-going auditory hallucinations. During the IDTT
meeting observed by this reviewer, the patient was observed to be in “full-issue” clothing but had
not been granted any privileges other than periodic showers. Although he denied any current
suicidal ideation or auditory hallucinations, there was no discussion regarding safety planning.
Following the IDTT meeting, this reviewer asked the treatment team why the patient had
not received consideration for any privileges during his 12-day MHCB stay. The PC replied that
privileges had not been granted until that meeting because “he was still experiencing
hallucinations.” When this reviewer then asked if the patient was going to remain in the MHCB
unit or referred to a higher level of care, the response was that the patient had been discharged to
EOP level of care. Such a response was surprising since it was not discussed during the IDTT
meeting.
With regard to safety plan training for mental health clinicians, the most recent
assessment found that only 12 of 23 or 52 percent of the audited facilities had compliance rates
of 90 percent or more. The overall rate of compliance for safety plan training in the 23 audited
facilities was 80 percent.
Finally, with regard to this reviewer’s previous recommendation that CDCR develop a
process by which each safety plan contained within the discharging SRE/SRASHE of a patient
released from a MHCB was reviewed by an SRE mentor at that facility, the recommendation was
accepted by the defendants, but implementation was initially delayed. In April 2018, CDCR
presented data from the Monthly MHCB Discharges Lists to this reviewer indicating that five
facilities (CHCF, CMC, CMF, CSP/Corcoran, and CSP/Sac) had multiple MHCB discharges
each day and it would be unduly burdensome and require additional staff to review every
discharging SRASHE in these MHCB units. After careful consideration, the following
corrective action was agreed to: (1) With the exception of CHCF, CMC, CMF, CSP/Corcoran,
and CSP/Sac, MHCB clinicians in all other CDCR facilities would be required to have all
SRASHEs reviewed by a mentor to ensure that each assessment contains an adequate safety plan
for reducing future suicidal ideation; (2) At CHCF, CMC, CMF, CSP/Corcoran, and CSP/Sac,
each MHCB clinician would be required to have at least one SRASHE reviewed by a mentor on
a weekly basis to ensure that each assessment contains an adequate safety plan for reducing
future suicidal ideation; and (3) At all facilities with an MHCB unit, the above safety plan review
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process would continue until 90-percent compliance has been achieved and maintained as
verified by quarterly audits.
Defendants’ May 2018 CAP was revised accordingly to incorporate the auditing process
for review of safety plans. The start date for the auditing process was not specified and was
pending revision of the EHRS, issuance of a “memorandum with new instructions,” and
webinar-based training for MHCB supervisors or designees responsible for the auditing.
In sum, safety planning to reduce the suicide risk of patients discharged from MHCB
units continues to be problematic throughout CDCR. As noted below in a forthcoming section of
this report (Section O: Suicide Case Reviews), approximately 25 percent of the quality
improvement plans resulting from inmate suicides during 2017 were in response to inadequate
SRE/SRASHEs and safety planning.
Finally, this reviewer and other members of the Special Master’s team attended a Safety
Planning Webinar conference call with staff from the Clinical Support Unit of the CDCR’s
Division of Correctional Health Care Services on July 19, 2018. The purpose of the webinar was
for CDCR to present a proposal that would allow clinicians a more reasonable and practical way
to develop safety plans through a concept entitled Safety Planning Intervention (SPI).6 Although
the SPI would include a “My Safety Plan” template, each plan would be individualized to the
patient’s needs. Overall, the Special Master’s team was impressed by the presentation and, with
some revision, encouraged the Clinical Support Team to implement the SPI model.7
Recommendation:
Initiation of safety plan auditing by MHCB supervisors or designees should be expedited
and a start date identified in the CAP. In addition, develop CAPs for safety plan training of
mental health clinicians in the 11 facilities that were below 90-percent compliance. The issue
should be monitored again by this reviewer during a proposed reassessment to ensure that the
CAPs have sufficiently resolved the deficiencies.
See Stanley, B. and Brown, G. (2012), “Safety Planning Intervention: A Brief Intervention to Mitigate Suicide
Risk,” Cognitive and Behavioral Practice, 19 (2012) 256-264.
6

The revisions included ensuring that the “My Safety Plan” template would include instructions (and training) to
ensure that the safety plan would be developed by both the patient and clinician, and not by the patient alone as
currently written. In addition, the 7-step template needed to be enlarged to include a step for specific group(s)
intervention. Further, Step 6 (“Making the Environment Safe”) needed to be revised for clarification (or even
deletion) to ensure that clinicians did not interpret this step to mean that the patient’s cell would be made physically
safe and/or means restrictions initiated in lieu of a MHCB referral for an otherwise suicidal patient. Finally, the
Clinical Support Team proposed that definitions needed to be created for “low,” “moderate,” and “high” suicide risk
to be incorporated into the SRASHE instructions, and that any patient assessed as being “low” acute suicide risk
would not be required to have a safety plan developed (unless they were being discharged from a MHCB). The
Special Master team supported this proposal with the stipulation that all patients discharged from an MHCB,
regardless of risk level, would continue to be required to have a safety plan developed. The Clinical Support Team
staff also suggested that there had been preliminary discussion within CDCR to revise the SRASHE template at
some point in the future to include revision of the chronic and acute risk factor checklists. The Special Master team
had concerns regarding substantial revision of the SRASHE but would defer any opinion until more information was
made available.
7

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K)

MHCB and Alternative Housing Discharge and Efficacy of Five-Day
Clinical Follow-Up and Custody Welfare Checks

Summary:
Consistent with the need for continued safety planning of patients released from MHCB
units and alternative housing to general population, administrative segregation, and other
housing units, this reviewer’s prior recommendations included strengthening existing procedures
for follow-up assessments by mental health clinicians and welfare checks by custody staff.
Defendants developed several memoranda and compliance forms to strengthen the follow-up
process. In March 2016, the “Interdisciplinary Progress Note – 5-Day Follow-Up” CDCR MH7230-B form was released in final format. The accompanying policy, entitled “Release of
Revised 5-Day Follow-Up Form,” was released on May 31, 2016. On January 27, 2016, CDCR
released a joint memorandum from the Director of the Division of Adult Institutions (DAI) and
Deputy Director of the Statewide Mental Health Program entitled “Revision of Mental Health
Crisis Bed Discharge Custody Checks Policy.” The policy required custody staff to observe an
inmate at 30-minute intervals for a minimum of 24 hours following MHCB discharge. The
policy also required that a clinician perform daily mental health assessments to determine
whether the 30-minute discharge checks were necessary beyond the minimum 24-hour
requirement (up to 72 hours), or whether the inmate required a referral back to a MHCB. On
September 1, 2017, CDCR officials released a slightly revised memorandum to include inmates
expressing SI and referred to, and discharged from, alternative housing “when clinically
indicated.”
Current Findings:
This reviewer’s most recent assessment included an audit of both the “Interdisciplinary
Progress Note-5-Day Follow-Up” (CDCR MH-7230-B) form process by clinical staff, as well as
the “Discharge Custody Check Sheet” (CDCR MH-7497) form process by both clinical and
custody staff. Overall, this reviewer found that clinicians (and nursing staff in their absence)
almost consistently completed “Interdisciplinary Progress Note – 5-Day Follow-Up” (CDCR
MH-7230-B) forms in all 23 audited facilities. However, similar to the chronic problem of
safety planning found in all of the facilities that had MHCB units, this reviewer continued to find
problems with concordance between the safety plans contained within discharging
SRE/SRASHEs and the safety plan summary sections of the CDCR MH-7497 forms. Although
some progress was noted, the safety plan summary sections of most forms simply recited
Program Guide requirements or contained narrative that was inconsistent with the safety plan of
the discharging SRE/SRASHE.
With regard to the discharge custody check process, a two-page “Discharge Custody
Check Sheet” (CDCR MH-7497) form was required to be completed on any inmate released
from a MHCB or alternative housing (“when clinically indicated”) placement. The first page
contained “discharging information” that was completed daily by the mental health clinician
when determining whether the 30-minute custody checks were to be continued up to 72 hours.
The second page represented the “custody checks” form completed by custody staff.
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This reviewer’s most recent assessment found that only three of 23 or 13 percent of the
audited facilities had clinicians and custody personnel correctly complete both pages of the
“Discharge Custody Check Sheet” (CDCR MH-7497) forms in 90 percent or more of the cases.
These three facilities were CCI, CCWF, and CMC. These findings were similar to those found
during the preceding review in which only 15 percent of the facilities audited for compliance
after mid-May 2016 had adequate practices for “discharge custody checks.” During this most
recent assessment, problems found in the remaining 20 facilities included clinicians not
completing the first page; clinicians discontinuing custody checks in less than the required 24
hours; custody checks performed at 60-minute, rather than 30-minute intervals, large gaps in
performed checks, and/or custody checks not being completed during the First Watch. The
overall compliance rate for the correct completion of Page One by clinical staff was 67 percent,
whereas the compliance rate for the correct completion of Page Two by custody staff was 77
percent. Finally, clinicians ordered discontinuation of 30-minute custody checks after the initial
24 hours in 48 percent of the cases, at 48 hours in 30 percent of the cases, and at 72 hours in 22
percent of the cases.
Defendants’ May 2018 CAP stated: “Workgroup formed to develop a statewide template
outlining the process, using CMC and SATF as models. This item will be monitored ongoing.”
Recommendation:
Utilize the Defendants’ May 2018 CAP for the “Discharge Custody Check Sheet”
(CDCR MH-7497) form process in the 20 facilities identified above that were below 90-percent
compliance. The issue should be monitored again by this reviewer during a proposed
reassessment to ensure that the CAPs have sufficiently resolved the deficiencies.
L)

Local SPRFITs

Summary:
Each local SPRFIT is required to meet at least monthly and carry out various
responsibilities including ensuring compliance with all CDCR suicide prevention policies and
procedures, five-day clinical follow-ups, safety plans, etc. Previous assessments by this reviewer
found that although the local SPRFIT concept was a valuable tool in CDCR’s suicide prevention
program, the process was not functioning as intended and needed to be rebooted. Most
importantly, many of the deficiencies identified by this reviewer in each prison were easily
observable and should not have been identified for the first time by a Special Master’s expert
and/or monitor, but rather by the local SPRFIT. Therefore, this reviewer’s previous
recommendation was for CDCR, under the guidance of the Special Master, to re-examine and
revise its local SPRFIT model to make the local SPRFITs a more effective quality
assurance/improvement tool. In February 2017, this reviewer’s critique of a revised draft
SPRFIT policy was submitted to CDCR.

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Current Findings:
In both February 2016 and October 2017, CDCR’s Statewide Mental Health Program
held multiple-day Suicide Prevention Summits to further discuss refinement of the SPRFIT’s
role in overall suicide prevention efforts within the department. All chiefs of mental health,
wardens, local SPRFIT coordinators, and supervisory custody personnel from the Mental Health
Compliance Team were invited to the meetings, among others, which were also attended by
several members of the Special Master’s team.
The court ruled on January 25, 2018 that “[g]ood cause appearing, defendants will be
directed to provide to the Special Master a local SPRFIT policy revised in accordance with Mr.
Hayes’ critique and the requirements of the Revised Program Guide, not later than thirty days
from the date of this order.” (ECF No. 5762 at 3.) On February 2, 2018, CDCR issued the
“Enhancements to the Suicide Prevention and Response Focused Improvement Teams”
memorandum that “clarifies, modifies, and establishes requirements and responsibilities.” The
revised memorandum became effective on March 1, 2018 and contained 19 responsibilities that
included, but were not limited to, monitoring suicide prevention training, treatment planning, and
five-day follow-up compliance; conducting root cause analyses of suicides and serious suicide
attempts; providing assistance and coordination for the activities of visiting Statewide Mental
Health Program (SMHP) and DAI suicide case reviewers following an inmate suicide;
conducting self-assessments related to compliance with suicide prevention items developed by
the SMHP’s Quality Improvement Unit; and maintaining a High Risk Management Program
consistent with CDCR policies and procedures.
Because the above memorandum was issued subsequent to completion of this reviewer’s
most recent suicide assessment, compliance with the new responsibilities of the local SPRFITs
was not audited. With that said, this reviewer’s most recent assessment continued to find few
positive SPRFIT practices at each facility. For example, the February 2, 2018 memorandum
clarified attendance requirements, including mandatory members and establishment of a
quorum.8 Had the memorandum been in effect at the time of the most recent facility
assessments, only three facilities (CMC, RJD, and PBSP) would have met quorum requirements
for the three consecutive monthly meetings that were reviewed. Of note, however, although
most local SPRFITs did not meet quorum requirements, a few, such as CIW, were quite active.
Review of SPRFIT meeting minutes at CIW reflected updated CAPs for continued suicide
prevention deficiencies, as well as regular discussion regarding SRE/SRASHE audits, High Risk
List, safety planning, Crisis Intervention Team, a planned Suicide Prevention Week, suicide
prevention posters and brochures, and robust summaries of recent serious suicide attempts,
among other issues. In addition, each meeting (which was 90 minutes in length) allowed time
for an inmate representative of the Suicide Prevention Outreach Committee to make a brief
presentation. Overall, however, SPRFIT monthly minutes in most of the 23 audited facilities
were unremarkable and continued to collect more quantitative than qualitative data, with only a
few establishing CAPs based upon this reviewer’s previous assessments.
8

According to Program Guide requirements for local SPRFITs (including the February 2, 2018 revision), a monthly
meeting quorum consists of attendance of mandatory members (SPRFIT coordinator, chief psychiatrist, chief
psychologist, supervising RN, senior PT or PT, correctional health services administrator, inpatient coordinator, and
associate warden for health care access) or approved designees.

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Recommendation:
No recommendations are offered related to this issue. The above described new local
SPRFIT responsibilities should be monitored again by this reviewer during a proposed
reassessment.
M)

Suicide Prevention Training

Summary:
Previous assessments of both pre-service and annual suicide prevention block training,
including the Mental Health Services Delivery System Instructor Guide, found some concerns
regarding content, length of training, and low completion rates for non-custody staff. As a result,
this reviewer initially made recommendations to expand the length and content of both the preservice and annual training workshops to include the following topics: (1) self-injurious v.
suicidal behavior and dealing effectively with inmates perceived to be manipulative, (2)
identifying inmates at risk for suicide despite their denials of risk, (3) updated research on CDCR
suicides, (4) identified problem areas and corrective actions from previous CDCR Suicide
Reports, and (5) results of recent Coleman audits of suicide prevention practices. This reviewer
made further recommendations that CDCR ensure that all custody and health care staff received
both pre-service and annual suicide prevention training, and that the workshops were conducted
by qualified mental health staff.
As previously reported, CDCR did not agree to expand the length of the pre-service
suicide prevention curriculum beyond 2.5 hours of the eight-hour pre-service Mental Health
Services Delivery System Instructor Guide curriculum. The curriculum was revised on several
occasions to include the recommended topics, and then again following this reviewer’s critique
of a full-day workshop at the Basic Correctional Officers Academy Training on December 7,
2015.
In addition, the annual suicide prevention training curriculum has been revised on several
occasions. This reviewer’s preceding assessment recommended—based upon observations
during several workshops that instructors were struggling to adequately present all of the
PowerPoint slide material within the two-hour allotted time frame and often using different
versions of the material—that CDCR should determine the adequate number of PowerPoint
slides that can reasonably be covered in a two-hour format and ensure instructors utilize the same
PowerPoint presentation.
Current Findings:
As offered in the preceding assessment, this reviewer most recently critiqued the eighthour pre-service MHSDS training at the Basic Correctional Officers Academy in Galt on
November 10, 2016. There were concerns about time management during the workshop, with
only 110 minutes (and not the required 150 minutes, i.e., 2.5 hours) devoted to the topic of
suicide prevention as required. In addition, only one of four role-playing scenarios was
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presented during the suicide prevention section. To date, this reviewer was informed that the
suicide prevention section of the pre-service Mental Health Services Delivery System Instructor
Guide curriculum has been again revised, but it has not been provided for review. In addition,
this reviewer has not been provided any scheduled dates to critique the revised full-day
workshop at the Basic Correctional Officers Academy Training. This reviewer continues to have
concerns as to whether the critical topic of suicide prevention can be adequately presented within
the currently allotted 2.5-hour time frame of the pre-service training curriculum.9
With regard to annual training, this reviewer’s most recent assessments found that 22 of
23 or 96 percent of the audited facilities had compliance rates for annual suicide prevention
block training of custody personnel that were at or above 90 percent, with the overall rate of
compliance in these 23 facilities at 97 percent.10
However, compliance rates for annual suicide prevention block training of both medical
and mental health staff remained very problematic. The most recent assessment found that 14 of
23 or 61 percent of the audited facilities had compliance rates for annual suicide prevention
block training of medical staff that were at or above 90 percent, with the overall rate of
compliance in these 23 facilities at 87 percent. The most recent assessment also found that 12 of
23 or 52 percent of the audited facilities had compliance rates for annual suicide prevention
block training of mental health staff that were at or above 90 percent, with the overall rate of
compliance in these 23 facilities at 85 percent. Compliance rates for suicide prevention block
training of medical and mental health staff were particularly anemic in three facilities (CMF,
CSP/LAC, and CSP/Sac), where compliance ranged from a low of 36 percent to a high of 80
percent.
Overall, only 10 of 23 or 43 percent of audited facilities were at or above 90 percent
compliance for annual In-Service Training (IST) suicide prevention block training of both
medical and mental health personnel. During this reviewer’s 2016 assessment, only 12 of 23
facilities had compliance rates at 90 percent or more. As such, this issue continues to remain
very problematic within CDCR.
In addition, during the most recent assessment, this reviewer and colleagues observed 16
IST suicide prevention training workshops. The strength of the IST workshops was the
instructors, all mental health clinicians who competently presented the required material. The
instructors were enthusiastic and engaged with workshop participants. However, problems
observed during the workshops included presentation of varying revisions of Version 3.1 of the
PowerPoint slides (ranging from 58 to 74 slides).11 The six case scenarios of suicidal inmates
9

This reviewer was recently informed that the suicide prevention portion of the Basic Correctional Officers
Academy Training was increased to four hours. A revised curriculum is in development.
10

Of note, the assessment also included compliance with CPR/AED training for both custody and medical personnel.
All of the 23 audited facilities had compliance rates for both custody and medical personnel that were at 90 percent
or more, with custody personnel having an overall compliance rate of 96 percent and medical personnel having an
overall compliance rate of 99 percent.
11

Version 3.1 was approved May 2016 and last revised in December 2017.

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were often either not presented or presented inadequately (e.g., the instructor choosing one case
and presenting it in a large group; at one workshop, case scenarios were not distributed and
participants broke into smaller groups and created their own case examples). Due to time
constraints predominantly caused by excessive slides, instructors rushed through the slides, did
not adequately present the case scenarios, and the post-test Knowledge Review either was not
completed at all or completed quickly as a group. Suicide Prevention Participant Workbooks
were rarely distributed during the workshops. Finally, each workshop generally had a small
group of participants that sat toward the back of the classroom and were disengaged from the
presentation, at times creating a distraction for the instructor.
In sum, the IST suicide prevention workshops were conducted by very competent and
enthusiastic instructors, but the sessions were compromised by the amount of information forced
into an allotted two-hour time period. In both February and October 2018, this reviewer
provided a written critique of the most recent version of the IST suicide prevention PowerPoint
slides to CDCR that included several specific recommendations for improvement.12
Defendants’ May 2018 CAP provided a schedule for revision and approval of the revised
IST suicide prevention training curriculum by various entities, including DAI, nursing
leadership, CDCR’s Office of Legal Affairs (OLA), and the Office of Training and Professional
Development. The CAP was estimated to be completed by December 2018.
Recommendation:

12

These recommendations included: (1) Slides 2.12 through 2.16 dealing with retrofitted new intake cells should be
deleted. All correctional personnel that work in administrative segregation units should already know what a new
intake cell looks like. The issue within CDCR is availability of new intake cells; (2) Slides 3.5 through 3.9 should
also be deleted. If needed, 3.8 and 3.9 can be moved into a previous slide dealing with warning signs and risk
factors; (3) Slide 4.4 regarding “denials of intent to self-harm” needs to be supplemented with additional slides that
provide an overview of why suicidal inmates deny their suicidal intent; (4) Consider consolidating or reducing
emergency response slides 5.3 through 5.8, while providing emphatic instruction that 911 needs to be called
immediately and can be initiated by authorized non-medical personnel. In addition, a slide needs to be revised with
new instructions that the cut-down tool is now in the emergency response bag and the entire bag should be brought
to the emergency; (5) Slides 6.1 thru 6.4 regarding the Suicide Case Reviews need to be revised to change the intent.
Most instructors who present these slides simply present them as a summary of good practices, rather than examples
of deficiencies identified in Suicide Case Reviews. For example, in Slide 6.2, instead of the narrative being “bring
the AED to the emergency scene and document its usage carefully,” the slide should read: “A significant number of
reviewed cases found that the AED was not brought to the scene and/or its use was not adequately documented”; (6)
Slides need to be created that visually demonstrate the serious repercussions from staff deficiencies. For example,
slides that show the number of staff that had been referred for investigation or other professional disciplinary action
might be of interest to an otherwise non-interested participant. For example, staff had been referred for investigation
or other professional disciplinary action for the following issues: failure to complete timely Guard One checks
and/or 30-minute discharge custody checks, failure to complete timely rounds of MHCB patients, failure to take the
inmate’s suicide threat seriously, failure to enter the cell and/or initiate 911 notification in a timely manner, etc.; (7)
Consideration for creating a few slides that provide summaries of several of the more egregious and preventable
suicides that have recently occurred within CDCR facilities; and (8) Consideration for local instructors to create a
few slides specific to their facility that provides a summary of recent Coleman and CQIT suicide prevention
assessments. There was a general feeling that most line staff attending the IST workshops had little appreciation
and/or knowledge of the suicide prevention audits.

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CDCR should provide the revised pre-service Mental Health Services Delivery System
Instructor Guide curriculum to this reviewer, as well as provide a schedule of possible dates in
which presentation of the revised curriculum can be observed at the Basic Correctional Officers
Academy Training. In addition, CDCR should develop CAPs for annual suicide prevention
training in the 13 facilities (CCI, CIW, CHCF, CMC, CMF, CSP/Corcoran, CSATF, DVI,
HDSP, CSP/LAC, PBSP, RJD, and CSP/Sac) that were below 90-percent compliance for suicide
prevention training for either medical and/or mental health personnel. Finally, CDCR should
incorporate this reviewer’s recommended changes to the annual IST suicide prevention training
curriculum that was previously forwarded in both February and October 2018.
N)

Continuous Quality Improvement

Summary:
By order of the Coleman court (ECF No. 4232, filed August 30, 2012; ECF No. 4561,
filed April 23, 2013; ECF No. 5092, filed March 3, 2014), defendants were directed to develop
an improved quality improvement process by which CDCR could identify issues and improve its
performance levels in the delivery of mental health care. The result was the development of a
Continuous Quality Improvement Tool (CQIT). During the course of the SPMW process,
CDCR agreed to incorporate this reviewer’s suicide prevention audit checklist into its overall
CQI process. The checklist included 19 measures.13
Current Findings:
A review of CDCR’s revised Continuous Quality Improvement On-Site Audit
Guidebook, last revised on July 2, 2018, found it included many, but not all, of this reviewer’s
suicide prevention audit measures. During SPMW and All-Parties Workgroup meetings in 20172018, CDCR consistently confirmed that the 19 suicide prevention audit measures would be
incorporated into either the CQIT or other CQI processes. To date, CDCR has not had the
opportunity to produce a CQIT report that includes findings from all of these 19 suicide
prevention audit measures.
Defendants’ May 2018 CAP stated that “CDCR to work with [Office of the Special
Master] on final report format, items are all added in the CQIT on-site tool. All items related to
timeliness are in the performance report. Training items are not automated but are collected by
our training unit and will be included in regional reports. New onsite items such as MHCB
13

The 19 measures were: Observation of R&R intake screening, confirming screening completeness and privacy and
confidentiality; Administrative segregation new intake inmates housed in retrofitted new intake cells for 72 hours;
Clothing allowance for MHCB patients; Treatment/safety planning for suicidal ideation in MHCBs; Use of
alternative housing; Annual suicide prevention training for custody staff; Five-day clinical and custody follow-ups
for MHCB returns; Guard One compliance; PT rounds in administrative segregation, SHU, and PSU; Suicideresistant design of MHCBs; Five-day clinical and custody follow-ups for alternative housing, DSH, and Psychiatric
Inpatient Program (PIP) returns; SREs required for emergency mental health referrals/TTA Log for suicidal
ideation; SREs required for admission/discharge in MHCB and alternative housing; Observation and Privileges for
MHCB patients; Emergency response equipment in housing units; Annual suicide prevention training for medical
and mental health staff; CPR training for medical staff; SRE Mentoring/Seven-hour SRE training and Safety
Planning training for clinicians; and SPRFIT responsibilities.

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privileges are in the on-site tool but are not yet coded. The findings will be included in the
written regional report and on the list to be coded for quantitative information. All new onsite
items will be completed by regional when onsite visits occur.”
Recommendation:
The reporting out of all of this reviewer’s 19 suicide prevention audit measures should be
encompassed in one final CQIT-formatted report for each facility, and not in various “regional
reports” as described in defendants’ May 2018 CAP.
O)

Suicide Case Reviews

Summary:
The MHSDS Program Guide provides detailed procedures in the event of an inmate
death by suicide. Following a suicide, the Division of Correctional Health Care Services’
(DCHCS) SPRFIT coordinator appoints a Suicide Reviewer to begin reviewing the case. The
primary purpose for the suicide review is to try to understand how the death occurred, what was
the precipitant(s) to the suicide, as well as any system failures that, once corrected, will allow the
agency to improve the suicide prevention program. The Suicide Reviewer examines all relevant
documentation in the case, including, but not limited to, the decedent’s central file, health care
record, and all relevant CDCR policies and procedures. The Suicide Reviewer is assisted by
both a custody supervisor from the Mental Health Compliance Team (MHCT) and a Nurse
Consultant Program Reviewer. The review also includes inspection of the decedent’s cell and its
contents, as well as interviews with select custody, medical, and mental health personnel,
inmates, and family members of the decedent when appropriate. Within approximately 30
calendar days of the suicide, the Suicide Reviewer is required to complete a preliminary Suicide
Report that contains relevant findings and recommendations, if any, for a quality improvement
plan (QIP) regarding the suicide. The preliminary report is forwarded to the DCHCS SPRFIT
Coordinator and the report is subsequently discussed at a Suicide Case Review subcommittee
meeting. Members of the subcommittee include SMHP staff, DAI and nursing leadership,
MHCT members, and OLA representative(s). In addition, leadership from the facility where the
suicide occurred is represented at the meeting. Members of the Special Master’s team are also
invited to observe the process. Following the subcommittee meeting, the Suicide Report is
finalized, and local facility leadership is required to implement any QIPs pursuant to a defined
schedule.
Current Findings:
A considerable strength of the CDCR suicide prevention program is the Suicide Case
Review process. Since at least June 2015, members of the Special Master’s team have reviewed
each preliminary Suicide Report and observed, as well as often participated in, the Suicide Case
Review subcommittee meetings. Although members of the Special Master’s team have provided
critiques of individual preliminary reports that have resulted in some revision of those reports,
overall, the Suicide Reports have been found to be not only very comprehensive but have

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provided thoughtful and targeted QIPs for correcting deficiencies and improving suicide
prevention practices.
During 2017, CDCR sustained 30 inmate suicides, with Suicide Reports developed in
each case. These reports, in turn, generated approximately 193 QIPs, which are listed in the
facility assessment sections in Appendix A of this report. The following list of categories
encompassed approximately 144 of the QIPs:14
•
•
•
•
•
•
•
•
•
•
•
•

Inadequate SRE/SRASHEs and/or Safety Plans: 36
Missing mental health documentation: 25
Nursing documentation (general): 21
Delay in 911 activation: 16
Delay in CPR initiation, cut-down kit retrieval, other: 16
Level of clinical care errors: 9
Psychiatric medication errors: 5
Nursing errors during emergency response: 5
Deficiencies in Guard One observation: 4
Failure to place inmate in new intake cell: 3
Inadequate housing of suicidal patient: 2
Nursing observation of suicidal patient: 2

Of significance, 25 percent (36 of 144) of the QIPs listed above involved inadequate
development of SRE/SRASHEs and/or safety plans.
Recommendation:
No recommendations are offered related to this issue.
P)

Reception Center Suicides

Summary:
During 2017, 30 percent (nine of 30) of the CDCR suicides occurred when inmates were
on Reception Center (RC) status. The suicides occurred at the following RC facilities: SQ (two),
WSP (three), and DVI (four). The number of RC suicides far exceeded those in recent prior
years.
Current Findings:
As a result of the high number of RC suicides within the CDCR system during 2017, an
RC Workgroup was initiated and has met periodically to study the issue. According to CDCR,

14

Of the 193 reported QIPs, many were duplicative (e.g., multiple QIPs generated for custody and nursing staff
based upon the same deficient emergency response, etc.), resulting in approximately 144 specific deficiencies
requiring a QIP.

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the workgroup was still gathering information, with plans to tour an RC facility in June 2018 and
then issue recommendations in the future.
During this reviewer’s most recent assessment, the mental health screening and
diagnostic evaluation process within the RC facilities (CCWF, CIM, DVI, NKSP, SQ, and WSP)
was observed. In addition, select RC housing units were inspected to determine whether suicide
prevention posters were located in visible locations. Overall, this reviewer observed that all
diagnostic clinicians conducted appropriate screenings in private offices that ensured both
privacy and confidentiality. With regard to the suicide prevention posters, pursuant to an earlier
CDCR initiative to increase suicide prevention awareness system-wide by distributing posters to
each CDCR facility, a memorandum to each facility’s chief of mental health (CMH) dated April
21, 2014 stated that “posters should be visible throughout your institution, particularly where
inmates congregate. They can be mounted near canteens, clinics, dayrooms, housing units,
workplaces, and Prison Industries Authority work areas.” Because the risk of suicide can be
particularly acute to an inmate newly-admitted into CDCR, placement of suicide prevention
posters in RC housing units should be considered a priority. This reviewer found that there were
inconsistent practices regarding the presence of posters within RC housing units in the toured
facilities, ranging from posters found in each unit, posters that were not prominently displayed
nor located in high-traffic areas, to an ill-informed decision to remove posters from bulletin
boards to allow room for other important announcements.
In addition, this reviewer’s review of a handful of cases involving RC inmates raised an
issue regarding both the availability and review of county jail records by diagnostic and other
mental health clinicians during the RC process. In one case involving the subsequent suicide of
an inmate at WSP in July 2017, the inmate was transferred to an MHCB the day after his RC
admittance. The suicide review found that MHCB clinicians did not have an opportunity to
review the inmate’s health care records from the county jail, presumably because the records
were not available for review at the time of the inmate’s MHCB placement. The review also
found that “policy and procedures for reviewing records received after evaluations have not been
clearly identified or communicated.” As a result of this case, a CDCR headquarters QIP was
developed and required that “HQ SPRFIT will evaluate the process used by clinicians when
reviewing jail records. Specifically, processes for reviewing jail records received after an
evaluation will be addressed. In addition, conditions that require further checks or an alert
system will be explored.”
In another case not resulting in suicide, this reviewer observed the mental health
screening and diagnostic testing process at CCWF in which one particular RC inmate selfreported an extensive history of mental health and suicidal behavior. Based upon the affirmative
responses, the inmate was referred for further mental health evaluation. Following the screening,
when the clinician was asked if they routinely reviewed both the intake health screening form
and any available discharge information from the county jail, the clinician responded by stating
that they and their colleagues responsible for the initial mental health screening waited until the
Mental Health Evaluation was completed before reviewing any previous records, including
county jail records.15 This reviewer’s concern with this clinician’s response was twofold: first,
This reviewer’s subsequent examination of the available county jail records indicated that the inmate had
attempted suicide by drug overdose approximately ten days prior to her arrival into CDCR, with a note indicating
15

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the MHSDS Program Guide only required a Mental Health Evaluation (“psychological
evaluation”) to be completed if the inmate answered affirmatively to any mental health questions
on the 31-item mental health screening form, and second, the Program Guide required the initial
Mental Health Evaluation to be completed within “18 calendar days,” although the process was
historically completed earlier. Under such a scenario, an inmate (not the one referenced above)
who provided all “no” responses to the mental health screening would not be referred for
completion of a Mental Health Evaluation and would not have either the initial intake screening
form or available county jail records reviewed by a mental health clinician. Of note, this
reviewer’s observation of the mental health screening and diagnostic testing process by another
CCWF clinician found that the county jail records were reviewed during the process.
Recommendation:
It is strongly recommended that the RC Workgroup include the following during its
deliberations: (1) CAPs in each RC facility to ensure that suicide prevention posters are placed
and maintained in visible locations in and around RC housing units, including, but not limited to,
housing unit bulletin boards, nurse’s offices where intake screening is administered, and pill call
windows; (2) ensure review and distribution of the HQ SPRFIT memorandum regarding the
results of the evaluation of “the process used by clinicians when reviewing jail records” as
related to the WSP suicide in July 2017; (3) the necessity to provide direction to clinicians
assigned to the RC diagnostic testing areas to ensure that they consistently review both the most
recent initial intake screening forms and any available county jail records prior to and/or during
completion of the 31-item mental health screening form; and (4) review Chapter 2 (“Reception
Center Mental Health Assessment”) of the MHSDS Program Guide to determine if unclear
language regarding requirements for review of health care information from both county jails
and prior CDCR confinements is in need of clarification.
IV.

Defendants’ Proposal to Build Temporary Unlicensed MHCB Beds at the California
Institution for Women and the R.J. Donovan Correctional Facility

In an effort to create more temporary MHCB options in CDCR’s southern region, as well
as reduce the length of stay in alternative housing system-wide, defendants identified two
facilities, California Institution for Women (CIW) and R.J. Donovan Correctional Facility (RJD)
for the temporary use of unlicensed MHCBs. At defendants’ request, this reviewer and another
member of the Special Master’s team inspected both proposed locations on April 11, 2018.
Specifically, the proposed locations were the GP Walker A Unit at CIW and a portion of the
3CMS and GP administrative segregation unit in Building 7 at RJD.

that “she is depressed about being here but does not want to die. Upset and emotional.” The county records also
indicated she had been prescribed an antidepressant. This reviewer’s examination of the EHRS indicated that the
inmate had recently been incarcerated at CIW and placed on suicide precautions. In addition to the recent county
jail suicide attempt, the inmate also had two recent suicide attempts by drug overdose in the community. This
information was available to, but not reviewed by, the mental health clinician at CCWF during the RC diagnostic
testing. Based upon this reviewer’s findings, the inmate was subsequently referred for completion of a SRASHE
which found a “high” chronic risk and “moderate” acute risk for suicide. Following review of all available records,
the clinician completing the SRASHE found “more concerning from information gleaned was IP actually was
minimizing history more than originally determined during the RC process.”

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The Walker A Unit at CIW is a one-story building with several wings, including an
outpatient housing unit and GP programming and office space. The proposed 18-bed unlicensed
MHCB unit would be located in a wing of the unit. To date, the 18-bed wing has already
undergone significant renovation, including repainting of walls and ceiling in each cell,
replacement of sink and toilet in each cell, and enlargement of exterior cell windows in each cell.
Such enlargement included three vertical exterior windows in the cells, each window measuring
approximately two-to-three feet in length. These windows provide a good amount of natural
light into all cells. Remaining renovation would include replacement of wall ventilation grates
with holes 3/16 in diameter in each cell, and installation of regular MHCB beds. The rooms
were otherwise suicide-resistant. Although slightly smaller than regular licensed MHCB rooms,
the cells would accommodate the new beds. In addition, the unit already contained two large
rooms that would be utilized for IDTT meetings, group programming, and other multi-purpose
reasons, including individual treatment. One cell would be converted into a nursing station in
the center of the wing, with another cell converted into an observation/seclusion room. Offices
for mental health clinicians would be located outside the MHCB unit in another wing of the
Walker A Unit. A medical examination room would also be located on the unit, but medical
providers would come onto the unit for most services. As proposed, the Unit courtyard would be
converted into a yard and designated only for MHCB patients. The courtyard would be
landscaped. An undetermined number of special management “walk-alone” yards would be
installed for patients on maximum security/administrative segregation unit statuses.
As proposed, this reviewer found CDCR’s proposal to convert CIW’s Walker A Unit into
a temporary unlicensed MHCB unit to be reasonable.
In stark contrast to the CIW proposal, defendants also proposed a temporary unlicensed
MHCB unit within the Building 7 administrative segregation unit at RJD. The proposed 20 cells
designated for MHCB patients would be located on the right side of the building. A chain-link
fence would be the only separation between the administrative segregation section and the
MHCB unit. As proposed, the administrative segregation section of the building would be
downsized to reduce the opportunity of administrative segregation inmates having visual
sightlines into the MHCB unit. However, as explained to the Special Master’s team, there were
no guarantees that an unforeseen increase in the administrative segregation population would
negatively impact sight and sound separation, and thus MHCB treatment.
As proposed, ten cells on both the first and second tier would be designated as MHCB
beds. Three cells on each tier (total of six) would be converted into clinical staff offices. One
cell on the first tier would be designated as an observation/seclusion room. Two cells, one on
each tier, would be converted into nursing stations. Two cells, one on each tier, would be
converted into interview rooms for clinicians. Additional cells would be converted into property
storage, medical supply, linen supply, and utility rooms.
As proposed, both therapeutic treatment modules (for patients on maximum-security/
administrative segregation statuses) and partition space (for patients on non-administrative
segregation status) would be created in the open dayroom for out-of-cell programming. MHCB
patients would be escorted outside the building to a conference room located in Building 6 (the
administrative segregation unit for EOP inmates) for their IDTT meetings. Although scheduled
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separately, the yard for MHCB patients would be the same as that designated for administrative
segregation inmates in Building 6 (3CMS/GP) and Building 7 (EOP). MHCB patients with
medical needs/appointments would be escorted to the Health Care Treatment Building located on
the opposite side of Building 6. Contrary to regular licensed MHCB units where most services
are provided internally, the anticipated increase in correctional officer responsibilities for
escorting patients in and out of the proposed MHCB unit has not been presented to the Special
Master’s team.
This reviewer found the following significant concerns during the inspection and
discussion (with CDCR headquarters and RJD officials) of the proposed unlicensed MHCB unit
at RJD on April 11:
•

Although all 20 cells would be retrofitted to be suicide-resistant (i.e., wall ventilation
grates replaced; desk, stool, and wall cabinet units removed; anti-squirt slit faucets
replaced, and bunks replaced with suicide-resistant beds), these cells would not be
enlarged (because the building could not structurally withstand removal of more than one
wall in the entire unit). In addition, although there was a proffer during a subsequent
conference call to install new cell doors with a larger window diameter, natural light
would still be very limited. The cells would remain dark, even with the offer to paint
cement walls, ceilings, and floors. In sum, the 20 cells that comprise this proposed
MHCB unit would simply resemble retrofitted new intake cells commonly found in
administrative segregation units.

•

The floor size of each cell would be that of an administrative segregation cell and, as
such, dramatically less than the traditional MHCB room found in licensed facilities.
Although initially informed that regular MHCB suicide-resistant beds would be installed
in each cell, with these beds taking up considerable floor space leaving significantly
reduced unencumbered space for patients to freely move about their cells, the Special
Master’s team was subsequently informed that MHCB suicide-resistant beds regularly
found in licensed MHCB units would not fit in these cells.

•

As noted above, two cells would be converted into clinical interview rooms. In addition,
two cells would be converted into nursing stations. Given the fact that inmates freely
converse through the ventilation grates and cell doors, even with clinical offices and
interview rooms located at the end of each tier, privacy and confidentiality could still be
compromised by the proposed location of these offices on each tier.

•

CDCR/RJD representatives informed the Special Master’s team that it would be very
challenging to schedule adequate yard time for MHCB patients because they would be
competing with administrative segregation inmates in Buildings 6 and 7 who are required
to attend yard separately. In addition, all MHCB patients (regardless of security
classification level) would be required to be placed in the special management “walkalone” yards because it is the only option available in the administrative segregation unit
yard.
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•

There were no plans offered to install fencing/netting on second tier railing to eliminate
the possibility of a suicidal patient jumping from the second tier in a suicide attempt.

This reviewer summarized the above serious concerns during an All-Parties Workgroup
meeting on April 23, 2018. In addition, the Special Master’s team had three other conference
calls with CDCR’s Statewide Mental Health Program leadership staff on May 1, June 7, and
June 26, 2018. As noted above, defendants revised their proposal during these calls to include
the painting of ceilings and walls in each cell, changing the cell doors to replicate new intake cell
doors, and proposing an increase of out-of-cell time to compensate for the extremely reduced
square footage of the cells compared to regular MHCB units. The latter proposal did not include
specifics, such as the type of out-of-cell time offered, schedules, and anticipated staff resources
necessary to accomplish increased out-of-cell time for 20 patients.
Following careful consideration of defendants’ proposal, including on-site inspection of
the administrative segregation unit at RJD and subsequent teleconference calls with Statewide
Mental Health Program leadership staff, as well as a review of both the defendants’ most recent
letter to the Coleman Special Master dated July 30, 2018 and plaintiffs’ letter in opposition to the
proposal dated August 8, 2018, this reviewer’s initial concerns remain unchanged. Despite the
best efforts of the CDCR leadership team, the proposed MHCB unit within an administrative
segregation unit at RJD would be stark and anti-therapeutic. Although cells would be retrofitted
to be suicide-resistant, they would remain cold, dark, and contain limited floor space well below
that of any licensed MHCB unit. They would simply resemble retrofitted new intake cells found
in administrative segregation units. Confidential office space could be severely compromised.
Availability for out-of-cell time, particularly yard, would also be extremely challenging. In sum,
activation of defendants’ proposal at RJD would result in deplorable conditions – unacceptable
for class members needing an MHCB level of care.
As detailed later in this report, the temporary and unlicensed 20-bed Mental Health
Outpatient Housing Unit (MHOHU) located at CSP/Sac has been problematic for many years.
There appears to be universal agreement among both parties that the MHOHU should be closed.
It would be this reviewer’s opinion that a proposal to transfer similar problematic conditions
historically seen within the MHOHU at CSP/Sac to RJD is simply not acceptable, and that
another non-administrative segregation setting should be considered.
V.

Conclusion and Recommendations

As stated in all of this reviewer’s previous assessments, it continues to be noteworthy that
CDCR, its management team (including statewide mental health staff) and legal counsel, as well
as local custody, medical, and mental health leadership at each of the prison facilities assessed
during 2017-2018, displayed total cooperation during this most recent suicide prevention
assessment process. CDCR’s implementation of this reviewer’s initial recommendations, as well
as the correction of existing and often chronic ongoing deficiencies, continues to progress at
varying speeds.

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As shown in the table below, there continued to be an increase in the number of inmate
suicides in CDCR during 2017, a great source of distress for all parties in the Coleman case. As
of December 27, 2017, CDCR housed 118,232 inmates (in-state within its institutions and
camps) and experienced 30 inmate suicides, resulting in a suicide rate of 25.3 deaths per 100,000
inmates.16
TABLE
AVERAGE DAILY POPULATION, OVERALL SUICIDES/RESTRICTIVE HOUSING
SUICIDES, AND SUICIDE RATES WITHIN THE
CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION
2013 THROUGH 2017*
Year
ADP17
All Suicides/Rate
Suicides in Restrictive Units/Percent18
2013
122,896
31/25.2
15/48.3
2014
119,069
23/18.7
14/60.8
2015
116,467
23/19.7
9/39.1
2016
117,612
27/22.9
10/37.0
2017
118,232
30/25.3
11/36.6
________________________________________________________________________
2013-2017
594,276
134/22.5
59/44.0
*Source: California Department of Corrections and Rehabilitation
Caution should always be exercised when viewing the above data. Suicide rates are most
meaningful when viewed over a sustained period of time and, as stated in this reviewer’s earlier
reports, although the total number of inmate suicides and the corresponding suicide rate in any
prison system can be important indicators, they are not the sole barometer by which adequacy of
suicide prevention practices should be measured. The best methodology for determining
whether a correctional system has fully implemented its suicide prevention program continues to
be (1) the assessment of suicide prevention practices within each prison, and (2) a review of each
inmate suicide in relation to practices in the prison and determining its degree of preventability.
In conclusion, it is again recommended that CDCR continue their efforts to fully
implement this reviewer’s previous recommendations, as well as develop CAPs based upon
deficiencies found in this most recent assessment. As shown below, most of these necessary
corrective actions are not necessarily based upon new recommendations, but rather by
CDCR’s continuing challenge of implementing and sustaining adequate suicide prevention

16

By comparison, the suicide rate in state prison systems throughout the country was approximately 20 deaths per
100,000 inmates in 2014. See Noonan, M. (2016), Mortality in State Prisons, 2001-2014 Statistical Tables,
Washington DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics (BJS). As of
August 2018, more recent BJS data was unavailable.
17

As of midnight, last Wednesday of year, includes in-state CDCR institutions/camps only.

18

Percent of suicides in administrative segregation, short-term restrictive housing, long-term restrictive housing,
SHU, PSU, and Condemned units compared to total CDCR suicides.

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practices. As such, CDCR should continue to cooperate with the Special Master and his experts
through the SPMW process to:
•

Develop CAPs for the intake screening process in the five facilities outlined
above in Section III. A;

•

Develop a work order for replacement of the wall and ceiling ventilation grates in
the MHCB unit at PBSP;

•

Develop CAPs in each of the ten facilities identified in Section III. D above to
ensure that newly-arrived administrative segregation inmates assigned to single
cells are placed in new intake cells for the first 72 hours of administrative
segregation confinement. Some of the CAPs may involve creating additional
retrofitted new intake cells, ensuring that all currently identified new intake cells
are suicide-resistant, and reinforcing the requirement that new intake inmates
should not be placed in non-intake cells when new intake cells are available;

•

Develop CAPs in each of the four facilities identified in Section III. E above that
continue to have alternative housing length of stays well in excess of 24 hours. In
addition, a CAP should be developed at CIM to ensure the correct calculation of
length of stay data in alternative housing;

•

In addition to CQI and regional mental health team audits, nursing supervisors at
each facility containing a MHCB unit should conduct regular EHRS audits to
ensure that suicidal patients are being consistently observed as required;

•

MHCB supervisors in each of the nine facilities identified above in Section III. G
should audit the possessions and privileges clinically ordered to MHCB patients
and report findings to the local SPRFIT committee until the issue is resolved. It is
also recommended that CDCR develop a CAP for recruiting a sufficient number
of RT personnel that can be assigned to MHCB units or, in the alternative, find
additional non-RT personnel to provide such services;

•

Develop CAPs for the six facilities identified in Section III. I above that continue
to struggle with completion of required SRE/SRASHEs for emergency mental
health referrals involving SI and SIB;

•

Initiation of safety plan auditing by MHCB supervisors or designees should be
expedited and a start date identified in defendants’ May 2018 CAP. In addition,
CAPs should be developed for safety plan training of mental health clinicians in
the 11 facilities identified above in Section III. J.

•

Utilize the Defendants’ May 2018 CAP for the “Discharge Custody Check Sheet”
(CDCR MH-7497) form process in the 20 facilities identified above in Section III.
K that were below 90-percent compliance;

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•

CDCR should provide the revised pre-service Mental Health Services Delivery
System Instructor Guide curriculum to this reviewer, as well as provide a
schedule of possible dates in which presentation of the revised curriculum can be
observed at the Basic Correctional Officers Academy Training. In addition,
CDCR should develop CAPs for annual suicide prevention training in the 13
facilities identified above in Section III. M that were below 90-percent
compliance for suicide prevention training for either medical and/or mental health
staff. Finally, CDCR should incorporate this reviewer’s recommended changes to
the annual IST suicide prevention training curriculum that was previously
forwarded in February and October 2018;

•

The reporting out of all of this reviewer’s 19 suicide prevention audit measures
should be encompassed in one final CQI-formatted report for each facility, and
not in various “regional reports” as described in defendants’ May 2018 CAP;

•

The RC Workgroup should incorporate the following issues during its
deliberations: (1) CAPs in each RC facility to ensure that suicide prevention
posters are placed and maintained in visible locations in and around RC housing
units, including, but not limited to, housing unit bulletin boards, nurse’s offices
where intake screening is administered, and pill call windows; (2) ensure review
and distribution of the HQ SPRFIT memorandum regarding the results of the
evaluation of “the process used by clinicians when reviewing jail records” as
related to the WSP suicide in July 2017; (3) the necessity to provide direction to
clinicians assigned to the RC diagnostic testing areas to ensure that they
consistently review both the most recent initial intake screening forms and any
available county jail records prior to and/or during completion of the 31-item
mental health screening form; and (4) review and revise Chapter 2 of the MHSDS
Program Guide (“Reception Center Mental Health Assessment) and/or Program
Guide revision to better clarify language regarding requirements for review of
health care information from both county jails and prior CDCR confinements; and

•

Defendants’ May 2018 CAP should be revised accordingly to incorporate the
recommendations contained within this assessment report.

Finally, as stated in previous reports by this reviewer, continuing re-inspection of select
CDCR facilities which chronically struggle with their suicide prevention programs is
recommended as it would allow for continued provision of technical assistance, a measurement
of the sustainability of CDCR’s corrective actions, and observation of the department’s CQI
process at individual facilities, leading to decreased future monitoring and hopefully continued
reduction of inmate suicides throughout the prison system.

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APPENDIX A

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Findings and Summaries of CDCR Suicide Case Reviews at 23 Re-Audited Prisons During
2017-2018
1)

California State Prison - Sacramento (CSP/Sac)

Inspection: May 23-25, 2017 (previous suicide prevention audit was on April 4-5, 2016).
CSP/Sac housed approximately 2,383 inmates at the time of the most recent on-site assessment.
Screening/Assessment: This reviewer observed a few new admissions during the intake
screening process in the R&R unit on May 24, 2017. The nurse was observed to be asking all of
the questions and correctly entering the information into the EHRS. The nurse’s office door was
closed during the process, thus ensuring both privacy and confidentiality.
Daily PT rounds in the short-term restricted housing (STRH) unit and one of the PSUs were
observed. The PT rounds were performed appropriately, with Psych Tech Daily Rounds
information entered into EHRS for each caseload inmate. The documentation process was
slowed by the recent implementation of EHRS (on May 9, 2017).
Housing: CSP/Sac had two CTCs; CTC-1 had 15 MHCBs and CTC-2 had ten MHCBs. This
reviewer previously found that all patient rooms within CTC-1 and CTC-2 were suicideresistant.
In addition, all cells in the 20-bed MHOHU (Mental Health Outpatient Housing Unit) were
previously designated to provide temporary, unlicensed MHCB level of care. Each cell was
suicide-resistant, and had solid cement beds, ventilation grates, and light fixtures. However, as
previously reported in the November 2013 assessment, the environment of the MHOHU
remained sterile. Cells still appeared dirty and dark, and offered limited visibility of their
interiors. Further, although IDTT meetings were conducted in an area outside of the housing
unit, there continued to be no clinician offices in the MHOHU, therefore, clinical assessments
were regularly conducted at cell-front or in therapeutic modules in the MHOHU. The modules
were located adjacent to large industrial floor fans (i.e., swamp coolers). Due to the excessive
noise, this reviewer observed that clinicians and IPs had a great deal of difficulty hearing each
other, negatively impacting the assessment process. In addition, because both nursing and
custody workstations were also located in the small high traffic dayroom area, adequate privacy,
confidentiality, and programming were severely compromised. As a result, many inmates
refused out-of-cell clinical appointments in the modules. Other observed deficiencies within the
MHOHU will be discussed below.
There were nine designated new intake cells (114-120, 217-218) in the administrative
segregation EOP unit (A-5) previously found to be suicide-resistant.19 In addition, there were
nine designated new intake cells (100-108) in the STRH unit previously found to be suicideresistant. This reviewer did not observe any new intake inmates in non-new intake cells in the
STRH unit during PT rounds.

For purposes of this report, “new intake cells” refer to designated cells in administrative segregation units that are
retrofitted to be suicide-resistant and house new intake inmates during the initial 72 hours of their confinement.
19

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Finally, alternative housing cells to temporarily house inmates awaiting MHCB placement were
used on almost a daily basis and primarily found in the B-7 Unit. This reviewer was informed
that the use of ZZ cells for inmates in alternative housing had ceased in November 2016. From
February 24 through May 17, 2017, there were approximately 223 inmates placed in alternative
housing, and all were provided beds and required to be observed on a continuous 1:1 basis. Due
to a shortage in nursing staff, all inmates were being observed by custody staff. According to the
available data, approximately 77 percent of inmates were discharged from alternative housing
within 24 hours, with 18 percent of inmates held over 24 hours and five percent over 48 hours.
The overall length of stay for all 223 inmates placed in alternative housing was 18 hours.
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCBs and MHOHU. In addition, patients not on suicide observation statuses were required to
be observed at 30-minute intervals. Nursing staff were observed to be using the new EHRS to
log observation rounds. This reviewer subsequently verified the accuracy of observation rounds
by reviewing the EHRS charts of three patients (SAC 1, SAC 2, and SAC 3) on Suicide
Precaution status in CTC-1, CTC-2, and the MHOHU during a nine-hour period from 12:00 a.m.
through 8:59 a.m. on May 23, 2017. The chart review found very few observation checks (i.e.,
two or three per patient) that were in excess of required 15-minute intervals, with the longest gap
between checks being 25 minutes in one case (SAC 3).
In addition, although this reviewer did not observe any obvious problems with the issuance of
possessions and privileges for patients assigned to CTC-1 and CTC-2, there were numerous
problems found within the MHOHU. For example, although an RT was assigned to the
MHOHU for 20 hours per week, the RT informed this reviewer that much of that time was
devoted to “assessments,” with only eight hours available for programming, resulting in most
MHOHU patients locked down in their cells 24 hours a day (with the exception of occasional
shower time). MHOHU patients were given the “choice” of either yard or therapeutic treatment
modules (TTMs). As described above, use of these TTMs was problematic. Review of custody
files for MHOHU patients indicated that access to the yard was rarely offered. Although
telephone privileges were often recommended by clinicians, telephone usage was non-existent
because the only telephone in the MHOHU dayroom had been deactivated since the unit opened
in 2009. The RT rarely attended IDTT meetings.
Finally, a review of Guard One data for a recent 24-hour period found an overall combined 99percent compliance rate with required checks not exceeding 35 minutes in STRH, administrative
segregation EOP, and PSU-A.
Despite these high completion percentages, it was noteworthy that the inmate suicide (SAC 8)
occurring in the PSU in June 2017 was found in rigor mortis despite completion of a timely
Guard One check, an indication that correctional staff did not adequately observe the interior of
the cell to verify “a living, breathing inmate” as required.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the Mental Health Tracking System (MHTS)
from April 1 through May 8, 2017. This reviewer’s sample eUHR review of 83 emergency
referrals for suicidal ideation/behavior revealed that clinical staff completed the required SREs in
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96 percent (80 of 83) of the cases, a significant improvement from the 87 percent completion rate
found during the 2016 assessment.
However, this reviewer examined 25 charts of patients recently discharged from the MHCB
units. The sample findings were problematic. Of the 25 cases, two (eight percent) were missing
discharging SREs. Of the remaining 23 cases, there was inconsistency ranging from adequate
safety plans to a safety plan narrative that simply recited Program Guide requirements. An
example (SAC 4) of an adequate safety plan of a CTC-2 patient was the following:
A plan to reduce his overall suicide risk includes: 1) Continue to help pt. develop
healthy lifestyle skills (sleep hygiene, appropriate exercise, spiritual activities,
ongoing skill-building around reality testing and sx recognition) to promote
maintenance of tx gains and to foster sense of self-efficacy in sx management.
Because his past reported SAs occurred as a result of CAH and psychotic-related
distress, the greater his sense of self-efficacy in managing these sxs, the less likely
he may be to feel overwhelmed or hopeless when experiencing sx recurrence; 2)
Pt expresses interest in further developing his reality testing and sx discernment/
recognition skills. Helping him to develop insight into his condition will likely
aid in this area, as well as development of concrete specific reality-testing
strategies; and 3) Help pt identify areas of hope and optimism in his life, CBT to
help him challenge rigid and distorted negative beliefs appear useful.
Unfortunately, this thoughtful safety plan was offset by the fact that subsequent five-day clinical
follow-up notes, as well as weekly PC progress notes, did not adequately reflect such safety
planning efforts.
Further, safety planning developed by MHOHU clinicians was consistently inadequate. Similar
to findings from the preceding assessment, at least one MHOHU clinician continued to use
virtually the same safety plan template for three patients (SAC 5, SAC 6, and SAC 7):
1)
2)
3)
4)
5)

IP will be released from MHCBU to EOP LOC.
He will receive weekly visits with a primary clinician.
Housing will include custody checks/monitoring q 30 mins.
He will receive weekly groups.
He will be released on a 5/8 day follow-up to monitor for reemergence of
suicidal ideation or crisis.
6) He will receive an IDTT within 14 days.
7) IP will work with clinician to develop coping skills for anxiety, mood
changes, and increased frustration tolerance.
8) It is recommended he work on managing frustration/anxiety and increase
distress tolerance. Also, utilizing time in prison positively by learning new
coping skills. Teach physical and mental activities that would increase
self-esteem, positive coping, and positive thinking.
The above safety plan is simply a restatement of Program Guide requirements, as well as
recommending that the patient “develop coping skills” without identifying any coping skills
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(which should have been part of the patient’s treatment during ten plus days of crisis bed
placement).
In addition, this reviewer was able to observe the IDTT processes in both CTC-1and CTC-2, and
to a lesser degree, in MHOHU, on May 25, 2017. IDTTs observed in CTC-1and CTC-2 were
adequate, with good case presentations and active participation from most treatment team
members. The IDTT process within the MHOHU was quite different, exemplified by an
atmosphere of harsh attitudes toward patients by treatment team members, including a few
unnecessary confrontational discussions.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 79 cases of inmates discharged from a
MHCB or alternative housing placement that remained at CSP/Sac and were not transferred to
administrative segregation (where observation at 30-minute intervals was required) during March
1 through May 17, 2017. The review found that only 14 percent had Page One of the “Discharge
Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental health clinicians.
Most of the custody checks were recommended for discontinuation after 24 hours by clinicians.
In addition, only 42 percent of the “custody check” forms (Page Two) were completed correctly
by correctional staff at 30-minute intervals, whereas 58 percent of the forms were completed in
excess of 30-minute intervals or completed in part or not at all. Due to the low percentage of
Page One of the forms being completed, the percentage of custody checks discontinued by the
clinician after 24 hours could not be determined.
Intervention: Housing units toured by this reviewer all contained an emergency response bag
that included a micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: Similar to prior assessments, a review of three months of SPRFIT meeting
minutes (February through April 2017) found that meetings consistently lacked all required
mandatory members or designees and quorums were not reached in any of the months. The issue
of “poor SPR-FIT meeting attendance” had been a monthly agenda item since 2012. With the
exception of discussing continuing problems with adequate completion of Discharge Custody
Check Sheets” (CDCR MH-7497), the meetings were otherwise unremarkable.
Training: According to training records, approximately 95 percent of custody staff and 100
percent of nursing staff were currently certified in CPR. In addition, 93 percent of custody staff
had received annual suicide prevention block training during 2016, but only 65 percent of
medical and 36 percent of mental health staff received comparable suicide prevention training
during 2016. The completion percentages for annual training of medical and mental health staff
continued to remain low. Finally, as of May 2017, only 69 percent of mental health clinicians
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had completed the SRE mentoring program, 90 percent had received the seven-hour SRE
training, and only 78 percent had received safety plan training.
Recent Suicides: CSP/Sac experienced one inmate suicide during the review period. In that
case (SAC 8), the inmate was found to have asphyxiated himself with a sheet in his PSU cell
during the afternoon of June 19, 2017. He was found in the state of rigor mortis. The inmate
entered CDCR for a third term on August 31, 2015 to serve a life sentence (with the possibility
for parole) for first-degree murder (of his mother’s boyfriend). He was transferred to CSP/Sac
on January 27, 2017. The inmate incurred 11 rules violation reports (RVRs) during his almost
two-year confinement, the most recent of which occurred on April 21, 2017 involving an assault
on another inmate. Of note, a subsequent mental health assessment found that there was an
association between the behavior that triggered the RVR and the inmate’s mental health issues.
The inmate was known to be gang-affiliated. He was unmarried and had one teenage son. The
inmate had family support from both his grandparents and son, and most recently received a visit
from his grandparents the day before his death.
The inmate had a difficult relationship with his parents and was primarily raised by his
grandparents. He had an extensive history of substance abuse and gang involvement as a
teenager but did not have any known mental health issues or treatment in the community. During
his two previous CDCR commitments, the inmate was treated at the 3CMS level of care within
the MHSDS. Upon entry into CDCR for the third term, he was initially treated for both
depression and anxiety at the 3CMS level of care beginning in late September 2015. The inmate
was subsequently placed in a MHCB six times for suicidal ideation, severe mood swings,
depression, anxiety, and long-term symptoms resulting from trauma. He was elevated to the
EOP level of care on April 25, 2016. His most recent MHCB placement was from May 6
through June 12, 2017 for danger to self and grave disability. Of note, the final day of his fiveday clinical follow-up was scheduled for June 19, the day of his death. The inmate had various
diagnoses during his CDCR confinement and was most recently diagnosed with Schizoaffective
Disorder (bipolar type), Substance Abuse Disorder, and Antisocial Personality Disorder.
The inmate had a history of suicidal ideation within CDCR, as well as a suicide attempt at the
NKSP Reception Center in late 2015 and an overdose from various medications in April 2016.
The majority of SREs determine his chronic risk as “moderate” and his acute risk as “low.”
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and other than chronic back pain,
the inmate did not have any significant medical issues that could be viewed as contributory to his
suicide. However, as previously stated, the inmate had a visit with his grandparents the day
before his death and they told a custody officer in a posthumous telephone interview that he had
apologized to them for the problems he had caused and stated sometimes “he no longer wanted
to be part of this world.” During interactions with staff and other inmates on a morning of his
death, the inmate was observed to be calm, alert, and cooperative. The CDCR reviewer
theorized that the suicide might have been influenced by the inmate’s “concerns regarding his
role in the family. Due to the fact that he murdered his mother’s boyfriend, he was rejected by
his mother and a number of his maternal family members. Several documents provide insight
into his feelings of profound guilt and having torn his family apart. Although he found comfort
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in a relationship with his paternal grandparents, who are now raising his son, he stated during
numerous encounters that he felt sad for not being able to be the father he wanted to be while in
prison.”
The Suicide Report contained seven recommendations for corrective action through a QIP:
1) An area of concern involves the condition which the inmate was discovered.
Based on reports submitted by responding staff, the inmate was discovered rigid,
with signs of rigor mortis and displayed a pale and bluish face, bluish bruise/
discolored areas on his shoulders, upper torso, upper/lower back, arms and feet.
Additionally, it was noted his neck was firm, eyes were bloodshot, and his jaw
was firmly shut with substantial rigidity.
This calls into question the thoroughness of the Security/Welfare checks
completed on Second Watch. Review of the Guard 1 ‘Rounds Tracker Summary’
identifies all checks were completed. However, it appears the visual/physical
observation of a living, breathing inmate, free from obvious injury as required did
not occur.
2) Prior to the arrival of the Ambu bag, no rescue breaths were provided through
the use of the CPR micro-shield which all custody staff are mandated to carry on
their person in the event of a medical emergency requiring its use.
3) Staff initiating CPR was observed conducting chest compressions using one
hand. Per CPR training, chest compressions shall be completed by placing the
heel of one hand in the center of the chest on the breastbone, while placing the
heel of the other hand directly on top of the first with fingers lifted or interlaced.
4) Per the CDCR 837s, staff discovering the inmate informed their partner the
sergeant was needed in the unit. The staff member walked away in order to notify
the sergeant their presence was needed in the unit via institutional radio. Upon
arrival the sergeant was informed by staff of the unresponsive inmate leading to
the sergeant instructing staff to retrieve the extraction gear. The sergeant
observes the inmate unresponsive and makes a radio announcement
approximately four minutes after discovery.
Sac’s OP 139 ‘Emergency Medical Response System’ identifies a custody first
responder shall briefly evaluate the inmate and situation and summon the
appropriate assistance by the most expeditious means available (e.g., personal
alarm device, two-way radio, whistle, shouting or telephone).
Requesting the sergeant to report to the housing unit via radio is not a valid means
of notifying necessary staff of the emergency.
5) Nursing Documentation, Multidisciplinary: 2/3/17, 2100-2135, no Suicide
Watch observations documented.
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6) Nursing Documentation, Nursing System Issue: 3/8/17, no PT Daily Rounds
located in the eUHR.
7) Nursing Documentation, Nursing System Issue: 5/5/17, 1000-1540, no Suicide
Watch documentation located in the eUHR.
2)

Wasco State Prison (WSP)

Inspection: June 8-9, 2017 (previous suicide prevention audit on August 16-17, 2016). WSP
housed approximately 5,265 inmates at the time of the most recent on-site assessment.
Screening/Assessment: This reviewer observed several new admissions during both the
medical intake screening process and the mental health diagnostic testing in the RC on June 8.
The nurse was using the most current version of the Initial Health Screening form (CDCR Form
7277) (revised July 2015), and was observed to be asking all of the required questions. The door
to the nurse’s office was closed, with the officer stationed outside, thus ensuring both privacy
and confidentiality. The door to the RC psychologist’s office was also closed and the clinician
was observed to be conducting thorough assessments. The psychologist was observed to have
access to (and used) the Patient Health Information Portal during the process.
Daily PT rounds in the administrative segregation unit were observed on June 9. The rounds
were unremarkable, and both PTs were observed to be correctly completing the Psych Tech
Daily Rounds Form at cell-front for all caseload inmates, as well as appropriately interacting
with non-caseload inmates.
Housing: WSP had an 18-bed CTC, with six rooms designated as MHCBs. A previously
identified problem of several rooms not being suicide-resistant because of antiquated ADA grab
bars (with openings between the bars and the walls that were conducive to suicide attempts by
hanging) were corrected less than a month prior to this writer’s assessment.
The administrative segregation unit had 14 cells identified for new intake inmates. Although 12
of the cells had previously been retrofitted as suicide-resistant cells and found to be appropriate
by this writer during previous assessments, two ADA cells (117-118) were recently designated
for new intake inmates and not suicide-resistant. These cells each contained two bunks, one of
which was situated in front of the exterior window allowing for a gap that was conducive to a
suicide attempt by hanging. In addition, each of the cells had antiquated ADA grab bars that
were not suicide-resistant. (During the exit meeting on June 9, this reviewer was informed that
the bunks situated in front of the exterior windows of cells 117-118 had been removed, and the
ADA grab bars would be replaced in the near future.) Further, this reviewer observed that all
new intake inmates were in new intake cells. Of note, a previous concern of exterior cell
windows containing frosted screening that obscured natural light into the cell had been resolved
with the screening removed from most exterior cell windows. The facility had received a
variance to allow for continued frosted screening on one section of the unit (Section A) due to
continued gang signage by inmates.

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Finally, alternative housing to temporarily house inmates identified as suicidal and awaiting
MHCB placement was used regularly on a daily basis. Most inmates were housed in Unit B-2.
From March 1 through May 31, 2017, there were approximately 179 inmates placed in
alternative housing. According to available data, approximately 87 percent of inmates placed in
alternative housing were released within 24 hours, with 13 percent held over 24 hours. Very few
inmates were held in alternative housing over 30 hours. All inmates were provided beds and
observed on a continuous 1:1 basis. The overall length of stay in alternative housing for these
179 inmates was approximately 15 hours.
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCB unit. In addition, patients not on suicide observation status were required to be observed
at 15-minute intervals by nursing staff. This reviewer was not able to verify the accuracy of
observation rounds because WSP had not yet implemented EHRS at the time of the on-site
assessment.
This reviewer was unable to observe any IDTT meetings in the MHCB unit because none were
scheduled during this on-site assessment. During the previous assessment in August 2016, this
reviewer had been informed by the IDTT that telephone calls and visits were not permitted in the
MHCB unit, and that they were awaiting further direction from CDCR headquarters regarding
the memorandum on “Mental Health Crisis Bed Privileges,” which was issued on June 23, 2016.
Yard privileges, however, were permitted and an RT was assigned to the CTC on a full-time
basis.
Upon return to the facility in June 2017, this reviewer again found that MHCB patients were still
not consistently receiving telephone calls and visits. In fact, a current Operational Procedure for
the CTC (No. WSP-013) still indicated that MHCB patients on either Suicide Watch or Suicide
Precaution status were not eligible for yard activities. In addition, a RT note dated April 18,
2017 regarding a patient’s (WSP 1) request for a telephone call stated that “custody explained to
I/P the protocol of not getting phone calls on MHCB. I/P refused session after learning this.”
This reviewer interviewed the RT assigned to the MHCB and found that only one of three
current RT positions were filled at the facility and the RT was dividing time between the CTC,
administrative segregation unit, and EOP program. As such, the RT spent only a few hours three
times a week in the CTC. The RT further stated that most MHCB patients did not refuse yard
when offered, although incorrectly stated that patients on Suicide Watch were not eligible for
yard.
Further, although the RT stated that MHCB patients received 30 minutes out of their room a few
times each week in the yard or the program office, a review of records suggested otherwise. For
example, this reviewer examined the records of 15 patients who each spent approximately nine
days in the MHCB during May 2017. The records indicated that patients were given the option
of either receiving yard or program office privileges, not both. In fact, most patients were not
even given the option of recreating in the program office, rather the RT interacted with them
cell-side. Of the 151 patient days for these 15 patients during May, there were only 39 RT
encounters, with 14 uses of the yard and 25 cell-side visits. In sum, except for the periodic
opportunity to shower, this reviewer found that MHCB patients spent an inordinate amount of
time confined in their rooms.
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Finally, a review of Guard One data for a recent 24-hour period in the administrative segregation
unit found 99-percent compliance with the required checks that did not exceed 35-minute
intervals. This was a significant improvement from the previous year in which only 88-percent
compliance was found.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS for the period of December 1, 2016
through June 5, 2017. The reviewer also reviewed the TTA log for the same time period. The
subsequent sample eUHR review of 41 cases of emergency mental health referrals for suicidal
ideation/behavior found that clinicians completed the required SREs in 90 percent (37 of 41) of
the cases.
A review of 15 charts of patients discharged from the MHCB unit continued to reveal
problematic safety planning. One clinician simply wrote a narrative in several safety plans that
the patients’ “should identify at least 5 coping skills to decrease depression, anxiety, and
impulsivity, promote successful prison incarceration with decreased ability of self-injurious
behavior, identify at least 3 goals for his incarceration” (see, for example, WSP 2 on May 11,
2017), thereby deferring the identification of appropriate coping skills to other clinicians. Other
safety plans continued to be limited to reciting Program Guide requirements and/or safety plans
not transferred from the discharging SRE onto the first page of the Interdisciplinary Progress
Note – 5-Day Follow-Up (CDCR MH-7230-B) form.
Of note, inadequate safety planning was listed as a prominent deficiency in one of the recent
WSP suicides (WSP 3).
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 136 cases of patients discharged from a
MHCB or alternative housing placement that remained at WSP and were not transferred to
administrative segregation (where observation at 30-minute intervals was required) from March
1, 2017 through June 2, 2017. The review found that only 37 percent had Page One of the
“Discharge Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental
health clinicians, although it should be noted that clinicians had high compliance rates for
accurate completion of Interdisciplinary Progress Note – 5-Day Follow-Up (CDCR MH-7230-B)
forms. Approximately 80 percent of the custody checks were recommended for discontinuation
after 24 hours by clinicians. In addition, only 84 percent of the “custody check” forms (Page
Two) were completed correctly by correctional staff at 30-minute intervals, including
approximately 16 percent of these cases involving checks not completed during the First Watch.

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Intervention: All housing units toured by this reviewer contained an emergency response bag
that included a micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months (March through May 2017) of SPRFIT meeting
minutes found that quorums were not reached in any of the months, with psychiatry staff not in
attendance at any of the meetings. Meeting minutes were very brief and otherwise
unremarkable.
Training: According to training records, both custody and nursing staff were at 100-percent
compliance with current CPR certification. In addition, 99 percent of custody staff, 91 percent of
medical staff, and 91 percent of mental health staff received annual suicide prevention block
training during 2016. Finally, as of June 2017, approximately 90 percent of mental health
clinicians had completed the SRE mentoring program, 90 percent had received the seven-hour
SRE training, and only 84 percent had completed safety plan training.
Recent Suicides: WSP experienced four inmate suicides during the review period. In the first
case (WSP 3), the inmate was found hanging from the top bunk of his general population cell by
a sheet during the early morning of April 26, 2017. The inmate entered CDCR through the RC at
WSP for his first term on February 28, 2017 to serve a 15-year sentence for assault with a
firearm. The committing offense involved holding his wife and several members of her family
hostage at gunpoint. He did not have any RVRs during his brief confinement. The inmate was
not known to be gang-affiliated and was raised by his mother. He experienced substance abuse
as a teenager but did not report any mental health issues in the community. He had no known
juvenile arrest history. At the time of the instant offense, the inmate was married and had a
young adult daughter. He did not have any visits or telephone calls during his brief confinement,
although there was some letter correspondence from a few of his family members, including his
mother.
During the RC assessment process, the inmate was diagnosed with Major Depressive Disorder,
recurrent, severe with psychotic features. He was initially placed at 3CMS level of care but
elevated to EOP a few weeks later after presenting with tearfulness, racing thoughts, sleeping
difficulties, and mild paranoia. Records also indicated that the inmate sustained a very serious
suicide attempt in the county jail on September 13, 2016, whereby he attempted suicide by tying
a ligature around his neck and jumping off the second tier of a housing unit. The attempt
resulted in the inmate being comatose for six days. He also self-reported another suicide attempt
by drug overdose in 2015 following an arrest on domestic violence charges.
The inmate began refusing both group treatment and psychotropic medication shortly after his
elevation to EOP on March 16, 2017. He denied any current suicidal ideation during two
separate SREs in February and March 2017 and was assessed as being “moderate” chronic and
“low” acute risk for suicide on both occasions. Apart from being served with divorce paperwork
approximately two weeks prior to his suicide, the CDCR reviewer in this case did not find any
specific precipitating factors that were known to staff indicating that the inmate was
contemplating suicide. Posthumous interviews with both staff and inmates indicated that the
inmate was quiet and often kept to himself. He did not have any significant medical issues that
could be viewed as contributory to his death.
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The Suicide Report contained three recommendations for corrective action through a QIP:
1) On February 28, 2017, the inmate was placed in the CCCMS program while
simultaneously being referred for placement in an EOP level of care. When asked
about this, senior mental health staff stated this placement and referral process
was put in place because inexperienced clinicians frequently make inappropriate
referrals and the process ensures appropriate placement referrals are made.
However, this additional process is not discussed in the MHSDS Program Guide
and may delay provision of EOP services and timelines meant for RC settings.
2) On March 14, 2017, a Suicide Risk Evaluation was completed that incorrectly
identified the inmate as not being a participant in the MHSDS and contained an
inadequate Safety Risk/Reduction Plan, stating only ‘No imminent risk symptoms
present during this evaluation.’
3) Activation of 911/Multisystem issue (Custody and Nursing): On April 26, 2017
at 0243 hours, the patient was found by custody to be hanging from his neck in
his cell. 911 was not activated until 0307 when TTA RN called Hall ambulance
to verify that call had been made. A 24-minute delay in activation of 911.
In the second case (WSP 4), the inmate was found hanging from the top bunk of his RC cell by a
sheet during the late evening of June 20, 2017. The inmate entered CDCR through the RC at
WSP for his first term on March 23, 2017 to serve a nine-year sentence for carjacking. He did
not have any RVRs during his brief confinement. The inmate was not known to be gangaffiliated. He was not married and did not have any children. The inmate did not have any visits
or telephone calls during his brief confinement, and had limited family contact, with no letter
correspondence found in his cell.
According to limited available records, the inmate was raised with three other older siblings by
an aunt who took guardianship when he was approximately six-months old. He was known to
struggle in grade school and became involved with substance abuse at an early age. As an adult,
a family member reported that he had been diagnosed with “borderline schizophrenia and
depression,” and periodically reported hearing “voices.”
During the RC assessment process, the inmate was diagnosed with Mood Disorder NOS, with
county jail records indicating a diagnosis of Schizoaffective Disorder. Psychotropic medication
was ordered, and the inmate was placed at 3CMS level of care. He quickly refused any mental
health treatment, including psychotropic medication. He denied any current or prior history of
suicidal ideation or suicide attempts (although there was an unconfirmed report by a family
member that he had attempted suicide in the community). The inmate refused to participate in
the completion of an SRE.
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and he did not have any significant

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medical issues that could be viewed as contributory to his death. Posthumous interviews with
both staff and inmates indicated that the inmate was quiet and often kept to himself.
The Suicide Report contained two recommendations for corrective action through a QIP:
1) Activation of the Emergency Medical System (calling 911) did not take place
until approximate 9 to 12 minutes into the emergency which caused significant
delay inappropriate medical response.
2) Medication non-compliance/non-adherence chronos were submitted (on 3/29,
4/18, 5/3, 5/9, 5/10, and 5/16); however, the inmate was not seen by psychiatry
until May 16, 2017. Medication non-compliance/non-adherence rules require the
patient to be scheduled for an appointment with a psychiatrist within five days of
the first refusal chrono. An appointment with a psychiatrist did not occur for
approximately seven weeks following the first medication refusal by the inmate.
In the third case (WSP 5), the inmate was found by his cellmate to be hanging from the top bunk
of his sensitive needs yard (SNY) cell by a sheet during the afternoon of July 6, 2017. The
inmate entered CDCR through the RC at WSP for his first term on March 24, 2017 to serve a
two-year sentence for corporal injury (on his spouse). He had one RVR during his brief
confinement, a battery on another inmate on May 13, 2017. He was not known to be gangaffiliated. The inmate had strong family support, including that of a fiancé. He also had a 7month-old baby and 7-year-old stepson. The inmate did not have any visits or telephone calls
during his brief confinement, but a significant number of cards and letters from his family were
found in the cell.
According to available records, both the inmate and his brother were primarily raised by his
mother, and all family members struggled with both substance abuse and mental illness. The
inmate, however, completed high school, was named salutatorian (second-highest in class), and
attended several colleges. He later became an avid bodybuilder and personal trainer, but his
escalating use of drugs, particularly methamphetamine, resulted in numerous arrests. These
records also indicated that the inmate had been hospitalized at least three times in the community
for psychosis. In the county jail, he had received treatment for “anxiety, mood swings, and
depression.” For the most part, the inmate consistently denied any current or prior history of
suicidal ideation or suicide attempts. The lone reference to a history of suicidal behavior was a
self-report in May 2017 that he had a “5150 commitment related to a serious suicide attempt by
hanging five years ago.”
Within a day of arrival to WSP RC, the inmate was admitted into a MHCB at CHCF for grave
disability following a custody mental health referral indicating that he “appears to be confused,
he is not able to respond to directions, he had a hard time focusing, he can’t think straight, he
does not want to go to SNY, first time in prison for corporal injury on his spouse.” During an
evaluation for MHCB admission, the inmate endorsed auditory hallucinations and appeared both
confused and highly disorganized. Although adequate documentation of his MHCB treatment
was lacking, he was viewed as an unwilling participant and refused most of the programming,
including his initial IDTT. He was discharged from the MHCB on April 7 at the EOP level of
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care after being assessed as “psychiatrically stable” because he was able “to maintain activities
of daily living, denying hallucinations, and denying suicidal and homicidal ideation.” The
inmate was returned to WSP to complete the RC process with a diagnosis of Psychotic Disorder
NOS.
During the next few months, the inmate was frequently non-compliant with the psychotropic
medication. He also refused several IDTTs, group sessions, and psychiatry appointments.
However, the CDCR reviewer in this case found several inconsistencies in the documentation of
the inmate’s mental health treatment. For example, although the inmate’s Treatment Plan
completed on May 11, 2017 indicated that “I/P has been showing up to 1:1 sessions with PC in a
cooperative manner……IP recently (as of last week) has stopped taking his psychotropic
medication and has been programming adequately per PC’s assessment and custody’s
assessment.” The CDCR reviewer found the Treatment Plan contained “several contradictions
and errors and does not summarize past mental health treatment (community hospitalizations,
county jail or MHCB) or ongoing problems related to refusing treatment (groups and telepsychiatry appointments).” During June 2017, the inmate continued to refuse most (25 of 27)
group sessions but did meet regularly with his PC. In a progress note dated July 5, 2017, one day
before the inmate’s suicide, the clinician wrote, in part, that:
I/P reported that he’s doing okay. I/P expressed that he does not get phone calls
and would like to speak with a counselor regarding if his father has passed away.
I/P reported that he does not like attending group but would make an effort on
attending. I/P expressed that no one directly told him that his father has passed
away, but he heard it through the air vents. I/P reported sleeping six hours per
night. I/P reported eating all of his meals. I/P reported that his cellmate can be
annoying at times. I/P denied being victimized by other inmates. I/P reported
being medication compliant but reported that he is going to stop taking his
medication because he heard through the air vents that staff is feeding him
estrogen. I/P expressed trying to distinguish reality from his hallucinations. I/P
reported that he believes riots are caused by him. I/P denied feeling SI or HI. He
expressed that he is not depressed, anxious, or manic. I/P denied having any
questions from the clinician.
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and he did not have any significant
medical issues that could be viewed as contributory to his death. However, the reviewer found
that there were several identifiable contributory causes to his death, including continuing
struggles with paranoia and auditory hallucinations. According to the reviewer:
It is likely his paranoia, auditory hallucinations, and depression prevented any
disclosure of suicidal thinking. While he appeared to have supportive family,
there were indications he was unsettled about his life (recently asking for
probation officer records and commenting to MHCB nursing staff that his
situation and his life was ‘bull....’). His perception of the status of his relationship
with the victim (fiancé) is unknown, but he mentioned to mental health he
received paperwork requesting child support.
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Posthumous interviews with both staff and inmates indicated that the inmate was quiet and often
kept to himself. However, his cellmate did indicate that he found the inmate lying on his bed
with a ligature around his neck three or four days prior to his suicide. For unknown reasons, the
cellmate never reported the incident to staff.
The Suicide Report contained nine recommendations for corrective action through a QIP:
1) The Mental Health Evaluation was not completed per policy at WSP. The
Brief Mental Health Evaluation submitted for the inmate’s MHCB referral
package did not include a review of records and was barely legible. The Mental
Health Evaluation that was completed on April 12, 2017 was based on limited
information because the inmate refused the interview and the evaluation did not
include a summary of jail records, MHCB treatment or review of the 5-day
follow-up or plan to rectify the incomplete evaluation.
2) The SREs dated March 25 and April 12, 2017 were incomplete, inaccurate, and
contained many inconsistencies. Subsequent documentation did not include a
thorough review of records, provide further clarification or address the poor
quality.
3) The WSP Mental Health Treatment Plans were not adhered to or updated to
reflect the inmate’s individual risk factors or problems. Information contained in
the Treatment Plans was inconsistent and at times inaccurate and did not include a
thorough review of the records or summary of treatment progress.
4) In review of his scheduled primary clinician appointments, there were several
progress notes missing from the unit health record. The dates of the missing notes
were the following: April 21, April 26, May 3, May 10, May 12, May 16, May 19,
May 23, and May 24.
5) The inmate refused four tele-psychiatry appointments (April 17, April 24, May
1, and June 5). Following his June 5 refusal his medication was stopped (Zoloft)
without having any contact with the patient or documented consult with unit
officers or primary clinician. There were also medication non-compliance
referrals submitted by nursing staff (on May 3, May 10, and May 17). The May
11, 2017 Treatment Plan mentions medication non-compliance but does not
discuss his tele-psychiatry refusals or discuss whether tele-psychiatry is
appropriate for this patient.
6) A Mental Health Evaluation was not completed at CHCF MHCB and the
submitted IPE was lacking in several areas (did not include a review of the
available records) and did not document any plan for additional follow-up to
rectify the inadequate evaluation.

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7) At CHCF MHCB, the SRE dated April 4, 2017 was incomplete and did not
provide a summary or analysis of available information.
8) The CHCF MHCB Initial and discharge Treatment Plans and Discharge
Summary were inadequate and did not include a summary of the treatment in the
MHCB, clear analysis of the presenting or current problems or a review of
available records.
9) When the inmate was admitted to CHCF MHCB in March 2017, jail records
were not available for review. Policy and procedures for reviewing records
received after evaluations have not been clearly identified or communicated.
In the fourth case (WSP 6), the inmate was found hanging from the top bunk of his general
population cell by a sheet during the late evening of October 15, 2017. The inmate entered
CDCR for his first term on August 15, 2016 to serve a six-year sentence for assault with a deadly
weapon. He was transferred to WSP on October 25, 2016. The inmate received 15 RVRs during
his 14-month confinement, the most recent of which occurred on September 14, 2017 involving
possession of alcohol. Due to his increasing disciplinary record, the inmate was pending transfer
to a Level IV facility at the time of his death. He was not known to be gang-affiliated. The
inmate had the limited family support from his grandparents and two uncles who provided letter
correspondence.
According to available records, the inmate was raised by his mother and several male
companions during his early years. Of note, his father committed suicide when he was only 6
years old. His grandfather described the inmate’s childhood as “dysfunctional at best.” He was
often physically abused by his step-father, and both drugs and alcohol were often used by his
mother and her male companions in the home while he was growing up. His grandfather
described him as a “lost soul.” The inmate was single and never married, and although records
indicated he had two children, the grandfather did not believe that such information was
accurate. The inmate had a significant substance abuse history, as well as a lengthy history of
arrests.
Records also indicated that the inmate had been diagnosed with Adjustment Disorder with
Depressed Mood in July 2016 while confined in the county jail system. Those records also
indicated a history of alcohol, methamphetamine, and heroin use, as well as two previous suicide
attempts. The suicide attempts apparently occurred in the community, the last of which occurred
at age 16 by drug overdose. Despite this information being documented in both the Initial Health
Screening and Mental Health Screening interviews, both dated August 15, 2016 at CIM RC, as
well as the mental health clinician noting that inmate’s “adaptive functioning was fair/poor and
that he had “continuing” mental health needs, the inmate was not considered for placement in the
MHSDS. He never requested any mental health services while confined at either CIM or WSP.
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and he did not have any significant
medical issues that could be viewed as contributory to his death. Posthumous interviews with
both staff and inmates did not uncover any significant information. However, in a subsequent
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interview with the inmate’s grandfather, the CDCR reviewer noted that his grandson had
“discussed concerns about his pending transfer to the Level IV institution in a letter received a
few weeks prior to his suicide. He thought this may have contributed to the suicide, in addition
to the remembering that his father (did commit suicide).”
Although the Suicide Report did not contain any recommendations for corrective action through
a QIP, the report noted several mental health and custody concerns. The mental health concern
was related to the inmate’s mental health and suicide attempt history not resulting in further
consideration for entry into the MHSDS, whereas the custody concerns were related to
inadequate emergency responses to the suicide. According to the CDCR reviewer, “all of the
concerns noted in this review have been addressed and action plans were implemented or
completed.”
3)

California Institution for Women (CIW)

Inspection: June 19-20, 2017 (previous suicide prevention audits on March 22-23, 2016 and
January 25-26, 2017). CIW housed approximately 1,907 inmates at the time of the on-site
assessment.
Screening/Assessment: The intake screening process within the R&R unit was not observed
because there were not any new inmates admitted into the facility during the two-day
assessment. In addition, this reviewer observed daily rounds by two PTs assigned to
administrative segregation, SHU, and PSU on June 20, 2017. The rounds in both units were
unremarkable and the two PTs were observed to be correctly entering Psych Tech Daily Rounds
information into EHRS for each caseload inmate.
Housing: CIW had a CTC with ten designated MHCBs. A previous deficiency of hazardous
faucets and sharp-edged sinks had been corrected and all MHCB rooms were now reasonably
suicide-resistant.
The administrative segregation unit contained seven retrofitted cells for inmates on new intake
status. Due to a low census during the on-site inspection, this reviewer observed very few new
intake inmates, and all were appropriately assigned to new intake cells.
Finally, the four “swing” medical beds (Rooms 7, 8, 9, and 11) in the CTC were primarily used
as alternative housing cells to temporarily house inmates awaiting MHCB placement. The
designated cells in the TTA and PSU could also be used for alternative housing. All inmates in
alternative housing within the CTC were observed on a 1:1 basis and were furnished beds.
Alternative housing continued to be used extensively at CIW. For the approximate six-week
period from May 1, 2017 through June 20, 2017, there were 59 inmates placed in alternative
housing, with only 20 percent discharged within 24 hours. The vast majority (80 percent) of
inmates averaged approximately 79 hours in alternative housing, and the overall length of stay
for all 59 inmates was 67 hours.
Observation: Both Suicide Precaution and Suicide Watch statuses were regularly used in the
CTC for patients identified as being suicidal. In addition, inmates not on suicide observation
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status were required to be observed at 15-minute intervals. This reviewer subsequently verified
the accuracy of observation rounds by reviewing the EHRS charts of five patients (CIW 1, CIW
2, CIW 3, CIW 4, and CIW 5) on Suicide Precaution status in the CTC during an eight-hour
period from 12:00 a.m. through 7:59 a.m. on June 19, 2017. The chart review found several
observation checks (between three and eight per patient) that were in excess of required 15minute intervals, with the longest gap between checks being 86 minutes in one case (CIW 5). In
another case (CIW 1), there were seven violations of 25-, 38-, 17-, 53-, 36-, 19-, and 22-minute
gaps between the required 15-minute intervals. Violations in the five cases were committed by
multiple nursing staff.
In addition, this reviewer observed the IDTT process in the MHCB on June 19-20, 2017 and
found that there were sound practices regarding approval of both possessions and privileges to
patients. MHCB patients were assigned clothing that was consistent with their level of
observation. A full-time RT was assigned to the unit and there appeared to be full use of both
the program office and yard for patients. This reviewer observed both a book cart and radio in
the yard. There also appeared to be full use of both telephone and visiting privileges, a
significant improvement from the previous assessment which had found confusion and
uncertainty regarding such privileges afforded to MHCB patients.
Five IDTT meetings were observed in the CTC. Overall, good discussions regarding suicide risk
and safety planning to reduce future recurrence of SI were observed, although most of the
discussion regarding safety planning was initiated and/or prompted by the MHCB supervisor
who was accompanying this reviewer.
Finally, a review of Guard One data for a recent 24-hour period found a combined 95-percent
compliance with required checks not exceeding 35-minute intervals in administrative
segregation, SHU, and PSU.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS and TTA log for the period of
January 1 through May 31, 2017. A total of 40 emergency mental health referrals were
randomly reviewed, with required SRASHEs completed in 93 percent (37 of 40) of the cases, an
improvement from the preceding assessment when only 89 percent of reviewed cases had
SRASHEs.
In addition, although this reviewer observed adequate discussion of safety planning during IDTT
meetings in the MHCB, subsequent review of ten charts of patients discharged from the MHCB
unit found uneven formulation of safety plans to reduce continued suicidal ideation. For
example, one case (CIW 6) provided the following adequate safety plan:
1) IP will use letter writing with peer in community as a way to keep hopeful and
will start first letter w/5 days and IP will share plan with PC.
2) PC will encourage IP to utilize journaling, with positive reframing, as a
positive coping skill to reduce anxiety/emotional distress and decrease SIB.

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3) PC will assist IP in utilizing MH staff when feeling depressed or urges to harm
self. PC will review co-pay and staff assistance process with IP at first contact to
work with IP on steps needed to make contact with PC and/or MH staff as needed
for emotional distress.
4) PC will work with IP on developing an exercise program that she can use
during heat warnings to maintain physical activity as this is a source of positive
relaxation as IP states that ‘exercise walking keeps my anxiety under control.’
5) PC will provide assertive communication skills and boundary skills to help IP
effectively verbalize needs related to self-care and setting limits with peers and
family.
The above safety plan was offset by another case (CIW 7) in which the clinician used the
following boilerplate safety plan on multiple patients discharged from the MHCB, as well as
deferred much of the safety planning to the primary clinicians of discharged patients:
1) IP will be on a 5-day step down.
2) PC will encourage and educate IP on medication compliance issues. PC will
discuss the importance of compliance with medication in stabilizing mood which
will assist IP in decreasing SI.
3) PC will explore with IP adaptive approaches to distressing situations in order to
increase her ability to problem solve during times of stress which lead to a crisis
state.
4) PC will provide anger management education and skill building to reduce
aggressive BX toward self and others and decrease negative thoughts that may
lead to self-harm.
5) PC will assist inmate in developing adaptive coping skills to cope with
situational stressors (anniversary dates) that may lead her to endorse suicidal
ideation, and to educate IP on grief/loss which will assist inmate in decreasing
negative thoughts which can lead to SI.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 155 cases of patients discharged from a
MHCB or alternative housing placement that remained at CIW and were not transferred to
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administrative segregation (where observation at 30-minute intervals was required) from March
1 through May 31, 2017. The review found that 85 percent had Page One of the “Discharge
Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental health clinicians,
with approximately 70 percent of the custody checks recommended for discontinuation after 24
hours by clinicians. In addition, only 75 percent of the “custody check” forms (Page Two) were
completed correctly by correctional staff at 30-minute intervals, with problems related to checks
completed at 60-minute intervals, gaps in documentation, and/or checks not completed during
the First Watch.
Intervention: All housing units toured by this reviewer contained an emergency response bag
that included a micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months (March through May 2017) of SPRFIT meeting
minutes found that, although there were between ten and 12 participants at each meeting,
meetings consistently lacked all required mandatory members or designees and quorums were
not reached in any of the months. With that said, the SPRFIT at CIW remained very active and
meeting minutes reflected updated corrective action plans for continued suicide prevention
deficiencies, as well as regular discussion regarding SRE review, High Risk List, safety
planning, Crisis Intervention Team, a planned Suicide Prevention Week, suicide prevention
posters and brochures, and robust summaries of recent serious suicide attempts, among other
issues. In addition, each meeting (which was 90 minutes in length) allowed time for an inmate
representative of the Suicide Prevention Outreach Committee to make a brief presentation.
Training: According to training records, 100 percent of custody staff and 94 percent of nursing
staff were certified in CPR. In addition, 98 percent of custody, 80 percent of medical, and 76
percent of mental health staff had completed annual suicide prevention block training during
2016. Finally, as of June 2017, 95 percent of mental health clinicians had completed the SRE
mentoring program, 90 percent had received the seven-hour SRE training, and 91 percent had
completed safety plan training.
Recent Suicides: CIW experienced one inmate suicide during the review period. In that case
(CIW 8), the inmate was found hanging by another inmate from the bunk by a shoelace in her
general population cell in the Fire Camp program during the early afternoon of August 23, 2017.
The inmate entered the CDCR system on January 17, 2017 to serve a four-year sentence for
burglary and stalking. She was transferred to CIW on March 29, 2017 and assigned to the Fire
Camp. The inmate did not incur any RVRs during her confinement and was not gang-affiliated.
She had telephone and letter correspondence with her mother, who she called on the morning of
her suicide.
According to limited available records, the inmate was raised by her mother following the
separation of her parents when she was a young girl. Her father subsequently died when she was
25-years-old. She was a high school graduate and reportedly obtained two college degrees, but
the accuracy of such information could not be verified. The inmate had a history of substance
abuse which was directly related to her instant offense. She had been in a 13-year relationship
with the victim of the crime, and the two had one daughter approximately 10-years-old.

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The inmate had been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) as a
young child and diagnosed with both Depression and Bipolar Disorder beginning at age 14. She
reported taking various psychotropic medication until 2013 when she lost her medical insurance
and began using methamphetamine. Prior records also indicated several residential treatment
programs for substance abuse, as well as reports of threatening suicide and engaging in selfinjurious behavior while attending these residential programs. Shortly after entering CDCR, the
inmate was placed in MHSDS at the 3CMS level of care on February 1, 2017 based upon
“medical necessity” of being previously prescribed psychotropic medication. Several days later
on February 6, 2017, she met with a psychiatrist, denied any current mental health symptoms and
requested a discontinuation of current medication. She was diagnosed with Stimulant Use
Disorder and Alcohol Use Disorder, moderate, “in a controlled environment,” and recommended
“continue therapy.” The following week on February 15, the inmate was removed from the
MHSDS, with no documented rationale for the removal. Although her prior history of selfinjurious behavior in residential treatment was known to clinicians, the inmate continued to deny
any current or prior suicidal ideation and behavior. There were no other documented reports of
self-harm or suicide attempts, and no SREs were completed during her incarceration. On March
29, 2017, the inmate was transferred to the Fire Camp program.
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and she did not have any significant
medical issues that could be viewed as contributory to her death. Posthumous interviews with
staff and inmates generally found they were all “shocked” by the suicide, although one inmate
peer stated that the inmate had “seemed more down” in the days leading up to her death. Several
un-mailed letters found in the inmate’s cell also did not give any indication of her impending
suicide. The inmate’s mother, who conversed with her daughter by telephone the morning of her
death, subsequently told the CDCR reviewer that she did not express any suicidal ideation during
the call but appeared depressed and physically exhausted from the Camp program. Following
discovery of her body on August 23, 2017, the following was written in ink on her left forearm:
“I’m tired…too just done.”
The Suicide Report contained two recommendations for corrective action through a QIP:
1) A MHPC initial assessment was conducted on February 1, 2017. This
assessment reference a review of the POR and included some general statements
about non-compliance with mental health treatment and psychiatric medication;
however, the assessment omitted information pertaining to the inmate’s prior selfharm, prior diagnosis and medication (since 14), and the progression of mental
health symptoms since 2013.
2) A February 6, 2017 psychiatric note indicated the inmate’s medication would be
decreased and discontinued and she should ‘continue therapy.’ However, the inmate was
removed from the MHSDS on February 15, 2017. There was no documentation of the
rationale for the decision to promptly remove the inmate from the MHSDS.

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4)

California Institution for Men (CIM)

Inspection: June 21-22, 2017 (previous suicide prevention audit was on March 24-25, 2016).
CIM housed approximately 3,637 inmates at the time of the on-site assessment.
Screening/Assessment: Due to scheduling conflicts, this reviewer was unable to observe both
the R&R unit intake screening by nursing staff and 31-item mental health screening by a clinical
psychologist during the RC process. There were, however, no issues raised in this area during
the preceding assessment.
Daily PT rounds in the administrative segregation unit (Palm Unit) were observed on June 22.
The rounds were unremarkable, and the PT was observed to be correctly completing the Psych
Tech Daily Rounds Form at cell-front for all caseload inmates. Of note, a STRH program had
been activated in the Palm Unit subsequent to the preceding assessment.
Housing: Two units of the CTC at CIM contained 34 MHCBs. All of the MHCB rooms
continued to be hazardous and were not suicide-resistant. For example, Unit 1 had rooms with
small gaps between the wall and window frame, faucet handles, and ventilation grates with large
holes in the ceiling (although the ceilings were high and not within easy reach) that were
conducive to suicide attempts by hanging. Unit 4 also had rooms with small gaps between the
wall and window frame, faucet handles, exposed toilet chase piping, and ventilation grates with
large holes in the ceiling (although the ceilings were high and not within easy reach) that were
conducive to suicide attempts by hanging. In fact, a patient attempted suicide by hanging from
one of the MHCB rooms on January 6, 2017. Each MHCB contained suicide-resistant beds.
The above deficiencies were first reported by this reviewer during an assessment in December
2013. During the March 2016 assessment, this reviewer was informed that although a work
order request was initiated by CIM officials sometime in 2014, the final design of the project had
not yet been approved. Although the headquarters work order schedule for MHCB renovation
previously examined by this reviewer did not contain reference to the CIM work, CDCR
informed this reviewer that the anticipated start date would be December 2016.
During the most recent assessment on June 21, 2017, this reviewer was presented with a ten-page
“Central Health Services Mental Health Crisis Bed (MHCB) Modification” plan dated December
21, 2016. The document was unsigned and CIM officials were unable to give this reviewer any
estimate as to when the MHCB renovation project would commence.20
In addition, this reviewer found that the Palm Unit contained 13 new intake cells that had been
retrofitted to be suicide-resistant. Although the unit had a low census, with only 78 inmates in

On January 25, 2018, the Coleman court ruled that “The ongoing existence of these conditions is unacceptable.
Good cause appearing, and defendants will be directed to provide to the Special Master and file with the court a
detailed plan for completion of all necessary work at CIM…” ECF No. 5762 at 2. On February 23, 2018,
defendants submitted a plan to the court which included the planned start (March 5, 2018) and the planned
completion (August 1, 2018) of the CIM renovation project. ECF No. 5795. On September 27, 2018, defendants
notified the Special Master that the MHCB unit renovations at CIM were complete.
20

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the 185-bed capacity unit, all of the new intake cells were occupied and this reviewer observed
two new intake inmates housed in unsafe, non-new intake cells.
Finally, alternative housing cells to temporarily house inmates awaiting MHCB placement were
used on almost a daily basis at CIM. Following this reviewer’s previous finding in March 2016
that inmates on alternative housing status were often placed in TTA tanks and holding cages
without access to water, toilets, or showers for extended periods of time, CDCR and CIM
officials relocated alternative housing options to Cypress Hall in Facility B (the RC building),
while still maintaining alternative housing in Cell 175 of the CTC and any available OHU room
within the CTC. This reviewer was provided data indicating that there were approximately 40
inmates placed in alternative housing during the three-month period of March 18 through June
18, 2017. However, the average length of stay in alternative housing could not be calculated
because of the unreliability of the data. For example, data indicated that one inmate (CIM 1) was
held in alternative housing for “zero” time on May 30, 2017, whereas observation sheets
examined by this reviewer indicated that the inmate was actually in alternative housing from
12:35 p.m. on May 30 through 2:15 p.m. on May 31, 2017, a period of almost 26 hours. In
another case (CIM 2), the inmate was listed as being held in alternative housing for “zero” time
on May 17, 2017, whereas observation sheets examined by this writer indicated that he was
actually in alternative housing from 3:00 p.m. on May 17 through 7:15 p.m. on May 18, 2017, a
period of approximately 28 hours.
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCBs. In addition, patients not on suicide observation status were required to be observed at
30-minute intervals. At the time of the on-site assessment, CIM had not yet implemented EHRS,
and nursing staff were still utilizing Suicide Watch/Suicide Precaution Record forms to
document the observation of patients on suicide observation status. Nursing staff still maintained
a poor practice of keeping the observation forms on a clipboard in the nurse’s office, and not
located on the outside of each patient’s room door. There were two patients on Suicide
Precaution status in Station 4 of the MHCB on June 22, 2017. A regional representative of the
CDCR Mental Health Compliance Team (MHCT) observed nursing rounds for these two
patients for approximately 90 minutes. Although nursing staff documented on the Suicide
Watch/Suicide Precaution Record forms that 15 checks were completed for both patients during
this time period, the MHCT representative observed nursing staff only completing four checks
on both patients during this period.
In addition, although this reviewer did not observe any obvious problems with the issuance of
possessions and privileges for inmates in the MHCBs during the 2016 assessment, there were
problematic practices found during the current assessment. This reviewer observed eight IDTT
meetings in the MHCBs on both June 21-22, 2017 and found that patients were assigned clothing
that was consistent with their level of observation. There was one full-time RT assigned to the
CTC, but this individual was responsible for providing services to up to 34 MHCB patients and
38 OHU patients. During several IDTT meetings, patients were either not informed about yard
and/or out-of-cell privileges, or in one case (CIM 3), informed that they were not eligible for
yard because they were on RC status, but because “you are no longer on Suicide Precaution
status, you’re eligible for groups.” Both instructions were incorrect. RC patients housed in the

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MHCB were eligible for yard, and all patients, regardless of their suicide observation status,
were eligible for groups, pursuant to the clinical judgment of IDTT members.
Observation of the eight IDTTs in the MHCBs showed mixed results. In some cases, there was
adequate discussion regarding patients’ current suicidal ideation and development of coping
skills to reduce such ideation, and other cases in which suicide risk and safety planning were not
discussed whatsoever. Two cases symbolize the uneven practices. In the first case (CIM 4), the
patient had written out his safety plan goals the previous night, discussed them with the PC in the
morning, and recited them during the IDTT meeting. The patient was discharged from the
MHCB that day (June 22), and the safety plan outlined on the discharging SRE stated the
following:
Pt. is optimistic about moving to the CCCMS LOC. He stated that he is willing to
actively participate in individual and group sessions. Pt. was motivated to create
a safety plan that includes the following items that he believes will help him to
cope with overwhelming emotions: reading, exercise, and using positive
affirmations that will help him remember to remain hopeful.
Pt. plans to decrease future conflict with staff, such as pending 115. He also plans
to find someone at his new facility that he feels he can establish rapport. This
person may be his PC, or someone in a CCCMS group, or an inmate or teacher
within an education or work-related program.
Pt. plans to focus on the positive aspects of his life and to start working on his
upcoming parole and family difficulties from a solution-focused perspective,
rather than problem focused.
In the second case (CIM 5), when asked during the IDTT what the triggers to his anxiety and
suicidal ideation were, as well as coping skills previously discussed with his PC, the patient
stated that he could not remember and appeared to be unfamiliar with the term “coping skills.”
Because neither the patient nor PC had previously written down any triggers or possible coping
skills, the awkward interchange ended.
A review of Guard One data for a recent 24-hour period found a combined 91-percent
compliance in the Palm Unit with required checks not exceeding 35 minutes.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS for the period of December 1, 2016
through June 15, 2017. In addition, the TTA log for a similar period was also reviewed. This
reviewer’s sample eUHR review of 50 emergency referrals for suicidal ideation/behavior found
that clinical staff subsequently completed the required SREs in 92 percent (46 of 50) of the
cases, a significant improvement from the 80-percent completion rate found during the preceding
assessment.
However, similar to the uneven presentation observed during the IDTT meetings, this reviewer’s
examination of ten sample SREs of patients released from a MHCB during April through June
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2017 found a mixture of adequate safety plan strategies to reduce SI with safety plan narrative
that simply deferred identification of coping skills strategies to the receiving PC.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 38 cases of inmates discharged from a
MHCB or alternative housing placement that remained at CIM and were not transferred to
administrative segregation (where observation at 30-minute intervals was required) during
December 2016 through May 2017. The review found that only 79 percent had Page One of the
“Discharge Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental
health clinicians. Of significance, approximately 71 percent of the custody checks were
recommended for discontinuation by clinicians after the maximum allowable 72 hours. In
addition, only 82 percent of the “custody check” forms (Page Two) were completed correctly by
correctional staff at 30-minute intervals, with problems related to checks completed at 60-minute
intervals, gaps in documentation, and/or checks not completed during the First Watch.
Intervention: All toured housing units contained an emergency response bag that included a
micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (April through June
2017) found that quorums were not achieved in any of the meetings, with consistent lack of
attendance from the correctional health services administrator, associate warden for health care
access, or their respective designees. The meeting minutes were otherwise unremarkable.
Training: According to training records, approximately 91 percent of custody staff and 100
percent of nursing staff were currently certified in CPR. In addition, approximately 89 percent
of custody staff, 97 percent of medical staff, and 99 percent of mental health staff received
annual suicide prevention block training during 2016. Finally, as of June 2017, 94 percent of
mental health clinicians had completed the SRE mentoring program, 83 percent had received the
seven-hour SRE training, and 96 percent had completed safety plan training. For the most part,
these completion rates for training were an improvement from the 2016 assessment.
Recent Suicides: CIM did not experience any inmate suicides during the review period.
5)

Kern Valley State Prison (KVSP)

Inspection: July 11-12, 2017 (previous suicide prevention audit was on February 23-24, 2016).
KVSP housed approximately 3,642 inmates at the time of the on-site assessment.

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Screening/Assessment: This reviewer observed a few new admissions during the intake
screening process in the R&R unit on July 11, 2017. The nurse was observed to be asking all of
the questions and correctly entering the information into the EHRS. The nurse’s office door was
closed during the process, the inmate was placed in a TTM, and an officer was stationed in the
hallway. Privacy and confidentiality were maintained.
In addition, this reviewer observed daily rounds by two PTs assigned to administrative
segregation and STRH units on July 12, 2017. The rounds in both units were unremarkable and
the two PTs were observed to be correctly entering Psych Tech Daily Rounds information into
EHRS for each caseload inmate.
Housing: KVSP had a 20-bed CTC, with 12 designated MHCBs. Previously identified hazards
(square-shaped stainless-steel sinks protruding from the wall and ventilation grates with holes
larger than the industry standard 3/16-inch diameter) were corrected in November 2016.
The two administrative segregation units (ASU-1, which housed EOP and 3CMS inmates and
ASU-2, which housed GP inmates) contained 13 retrofitted cells for inmates on new intake
status. During the tour of ASU-2, which contained five retrofitted cells and were all occupied,
this reviewer found that two new intake inmates were housed in unsafe, non-new intake cells.
Finally, alternative housing cells to temporarily house inmates awaiting MHCB placement were
primarily found in ASU-1 and SNY units, as well as occasionally in other designated cells
throughout the facility. Alternative housing was used on a daily basis, and inmates were all
furnished beds and observed on a 1:1 basis. From April 1 through June 30, 2017, there were
approximately 167 inmates placed in alternative housing, and the vast majority (83 percent) was
released within 24 hours. Few inmates were held in alternative housing over 48 hours. The
overall length of stay in alternative housing for these 167 inmates was 19 hours.
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCB. In addition, patients not on suicide observation status were required to be observed at
30-minute intervals. This reviewer subsequently verified the accuracy of observation rounds by
reviewing the EHRS charts of four patients (KVSP 1, KVSP 2, KVSP 3, and KVSP 4) on
Suicide Precaution status in the CTC during an eight-hour period from 12:00 a.m. through 7:59
a.m. on July 10 or July 11, 2017. The chart review found numerous observation checks (i.e.,
between 11 and 12 per patient) that were in excess of required 15-minute intervals, with the
longest gap between checks being 66 minutes in one case (KVSP 1). The following case (KVSP
4) exemplifies the significance of the problem: There were 11 violations of 18-, 28-, 33-, 21-,
27-, 18-, 29-, 32-, 25-, 23-, and 18-minute gaps between the required 15-minute intervals.
Violations in the four cases were by multiple nursing staff. This reviewer was subsequently
informed by nursing staff that (as part of the issue, but certainly not a full explanation) there was
a shortage of available laptops to enter observation rounds into EHRS, resulting in staff making
handwritten notes and entering the information when a laptop became available.
A previous problem with patients being clothed in safety smocks while being observed at 30minute intervals had been corrected, and all patients were observed to be appropriately clothed
consistent with their level of risk. An RT was assigned to the MHCB unit for 30 hours per week
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and attempted to allow each patient yard privileges at least once a week (on Thursdays). In
addition, custody staff assigned to the MHCB was available to provide yard during other days.
Patients were said to be afforded both visitation and telephone privileges.
Three IDTT meetings were observed in the CTC. Overall, there was adequate discussion
regarding suicide risk and safety planning to reduce future recurrence of SI in each case.
However, as indicated below, the adequacy of safety planning discussed during IDTT meetings
was not transferred into adequately written safety plans upon discharge from the MHCB.
Finally, a review of Guard One data for a recent 24-hour period found a combined 99-percent
compliance in both ASU-1 and ASU-2 with required checks not exceeding 35-minute intervals.
Management/Treatment Planning: This reviewer requested and subsequently received a list of
emergency mental health referrals from the MHTS for the two-month period of May and June
2017. This reviewer’s sample EHRS review of 21 emergency referrals for suicidal
ideation/behavior revealed that clinical staff completed the required SREs in only 76 percent (16
of 21) of the cases. Completion of SREs for inmates housed in alternative housing was also
audited. The sample review found that required SREs were completed in 90 percent (73 of 81)
of cases.
This reviewer examined a sample of ten SRE/SRASHEs from patients released from a MHCB
between April and July 2017. Only two SRE/SRASHEs were adequate. Most of the remaining
assessments were written by one particular clinician assigned to the CTC at the time. The
following are the entire safety plans from this clinician for five patients discharged from the
MHCB:
KVSP 5: IP will return to previous level of care. It is recommended IP treatment
plan should include effective communication, 5-day FU, 3-day custody FU.
KVSP 6: Return to CCCMS, reinforcement of positive coping skills to manage
stress. Weekly contact and groups while in Ad Seg for continuity of care.
Psychoeducation on the importance of alerting staff before SIB of biting self.
KVSP 7: Return to EOP for weekly therapy and groups. Psychoeducation for
reinforcement of positive coping and CBT for challenging faulty thinking and
management of AH.
KVSP 8: Placed IP in MHSDS for treatment. Ongoing contact with clinician to
discuss additional coping to manage reported anxiety/stress/paranoia. Continue
medication regime.
KVSP 9: EOP level of care, increase from CCCMS.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.

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A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 207 cases of inmates discharged from a
MHCB or alternative housing placement that remained at KVSP and were not transferred to
administrative segregation (where observation at 30-minute intervals was required) from January
1 through June 30, 2017. The review found that only 48 percent had Page One of the “Discharge
Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental health clinicians,
with approximately 72 percent of the custody checks recommended for 48 hours or more by
clinicians. In addition, only 79 percent of the “custody check” forms (Page Two) were
completed correctly by correctional staff at 30-minute intervals, with problems related to gaps in
documentation and/or checks not completed during the First Watch.
Intervention: All toured housing units contained an emergency response bag that included a
micro-shield, Ambu Bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (April through June
2017) found that quorums were not achieved in any of the meetings. The meeting minutes were
otherwise unremarkable.
Training: According to training records, approximately 95 percent of custody staff and 100
percent of nursing staff were currently certified in CPR. In addition, approximately 98 percent
of custody staff, 92 percent of medical staff, and 93 percent of mental health staff received
annual suicide prevention block training during 2016. Finally, as of June 2017, only 47 percent
of mental health clinicians had completed the SRE mentoring program, 92 percent had received
the seven-hour SRE training, and only 72 percent had completed safety plan training.
Recent Suicides: KVSP experienced one inmate suicide during the review period. In that case
(KVSP 10), the inmate was found hanging from the top bunk by a sheet in his GP cell shortly
before midnight on March 21, 2017. The inmate entered the CDCR system in February 2010 to
serve a 77-year-to-life sentence for first-degree murder and attempted murder. He was
transferred to KVSP in January 2013. The inmate incurred four RVRs during his confinement,
the most recent of which occurred in April 2015 for possession of a controlled dangerous
substance. He was not known to be gang-affiliated. The inmate had good support from family,
including monthly visits from his grandmother, periodic visits from his mother, sister, and son;
as well as letter correspondence.
According to available records, the inmate had a dysfunctional childhood, his father was in
prison and he was raised initially by his mother, and then by his grandparents when his mother
remarried, and he did not get along with the stepfather. The inmate was never married and was
estranged from the mother of his 4-year-old son at the time of the instant offense. He had a
history of substance abuse beginning at age 14 and his addiction escalated following two serious
motorcycle accidents when he was 21.
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The inmate did not have a history of any mental health treatment in the community. Upon entry
into CDCR, the inmate answered affirmatively to several questions which triggered further
mental health evaluation for a possible mood disorder. He was initially diagnosed with
Polysubstance Dependence, Hallucinogen Persisting Perception Disorder, with a rule out of
Bipolar Disorder. The inmate denied any current SI, and records indicating two prior suicide
attempts in the community were unconfirmed. He was discharged from the MHSDS several
months later in July 2010 when he refused further treatment and was found to be stable. The
inmate’s final contact with mental health staff occurred in January 2012 following a custody
referral. He was found not to meet the criteria for MHSDS.
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and although he continued to suffer
from severe chronic back and knee pain sustained from motorcycle accidents at age 21, these
medical issues were not viewed as proximate causes of his death, but perhaps as contributory. In
addition, there was information found in his cell after the suicide to indicate he might have
accrued gambling and/or drug debts that he could not repay. In a suicide note found in the cell
and addressed to his grandmother, the inmate wrote: “I’m sorry but I just can’t do this anymore.
I am sick of being a burden and I need to be free and see what comes next. I made it further than
I ever thought I would. Thanks to your undying love and support.”
The Suicide Report contained three recommendations for corrective action through a QIP:
1) While the check boxes on the SRAC (11/10/2010) and SRE (11/23/2011) were
marked correctly and individualized risk factors appeared to be considered in the
assessment of risk, the second pages containing the mental status exam,
justification of risk, and safety planning/risk reduction were poorly completed on
both evaluations. The suicide risk assessments contained inadequate case and risk
formulation and safety planning/risk reduction. Further, despite improvements in
policies, procedures and trainings, insufficient case/risk formulation and safety
planning continues to be an ongoing statewide issue.
2) The CDCR 837s submitted by responding staff identifies a cut down kit was
not taken to the scene of the emergency in its entirety.
3) Activation of the Emergency Medical System (calling 911) did not take place
until approximately five minutes into the emergency which caused a delay in
appropriate medical response.
6)

North Kern State Prison (NKSP)

Inspection: July 13-14, 2017 (previous suicide prevention audit was on February 25-26, 2016).
NKSP housed approximately 4,583 inmates at the time of the on-site assessment.
Screening/Assessment: This reviewer observed a few new admissions during the intake
screening process in the R&R unit on July 13, 2017. The nurse was observed to be asking all of
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the questions and correctly entered the information into the EHRS. The 31-item mental health
screening by a psychologist in the RC was also observed and found to be thorough. Doors to
both the nurse’s and clinician’s offices were closed during the processes, thus ensuring privacy
and confidentiality.
Daily PT rounds in the administrative segregation unit (D-6) were observed on July 13. The
rounds were unremarkable, and the PT correctly entered the Psych Tech Daily Rounds
information into the EHRS for each caseload inmate.
Housing: NKSP had a 16-bed CTC, with ten designated MHCBs. A previously identified
hazard of ventilation grates with holes larger than the industry standard 3/16-inch diameter were
corrected prior to this current assessment in October 2016.
In addition, the administrative segregation unit (D-6) had a total of 13 new intake cells that had
been retrofitted to be suicide-resistant. This reviewer observed that all new intake inmates were
correctly housed in new intake cells.
Finally, alternative housing cells continued to be designated in A-4 Unit to temporarily house
suicidal patients prior to transfer to a MHCB, although some were occasionally held in the
administrative segregation unit. This reviewer observed two inmates on alternative housing
status on July 13. Both were being observed on a 1:1 basis and bunks were found in each cell.
During the three-month period of May 1 through July 10, 2017, there were approximately 101
inmates placed in alternative housing, with 91 percent released within 24 hours. Only one
inmate was held more than 48 hours. The overall length of stay in alternative housing for the
101 inmates was 16 hours.
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCB. In addition, patients not on suicide observation status were required to be observed at
15-minute intervals. This reviewer subsequently verified the accuracy of observation rounds by
reviewing the EHRS charts of four patients (NKSP 1, NKSP 2, NKSP 3, and NKSP 4) on
Suicide Precaution status in the CTC during a nine-hour period from 12:00 a.m. through 8:59
a.m. on July 13, 2017. The chart review found numerous observation checks (between nine and
15 per patient) that were in excess of required 15-minute intervals, with the longest gap between
checks being 59 minutes in one case (NKSP 1). The following case (NKSP 4) exemplified the
significance of the problem: There were nine violations of 18-, 17-, 16-, 19-, 17-, 23-, 37-, 32-,
and 36-minute gaps between the required 15-minute intervals. Violations in the four cases were
by multiple nursing staff.
A previous problem with patients being clothed inconsistent with their level of suicide risk, as
well as routinely denied telephone and visiting privileges, had been corrected. An RT was
assigned to the MHCB unit for 40 hours per week and utilized the yard on a daily basis. Review
of pertinent records indicated that telephone and visiting privileges were authorized, and yard
was found to be offered to patients several times per week.
Five IDTT team meetings were observed in the CTC. Overall, there was very uneven discussion
regarding patients’ current suicide risk and safety planning. In one case (NKSP 5), the patient
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was on Suicide Watch status and had been clothed in a safety smock for eight consecutive days
without any explanation or discussion of his suicide risk. There was also no discussion regarding
a possible psychiatric inpatient program (PIP) referral until outside reviewers raised the issue. In
another case (NKSP 2), the patient had been in the CTC since June 29, 2017, a period of 16 days.
He denied any suicidal ideation, had been given full-issue clothing for several days, but still
complained of depression and requested to stay in the MHCB for another week. The request was
granted, and he was subsequently discharged back to the yard (and not higher LOC) five days
later on July 19, 2017, for a total length of stay of 20 days. His discharge safety plan is
discussed below. In a third case (NKSP 1), the inmate was discharged during the observed IDTT
team meeting on July 14 with no discussion regarding safety planning.
A review of Guard One data for a recent 24-hour period found 99-percent compliance with
required checks not exceeding 35-minute intervals.
Management/Treatment Planning: This reviewer requested and subsequently received a list of
emergency mental health referrals from the MHTS for the period of January 1 through June 30,
2017. This reviewer’s sample EHRS review of 42 emergency referrals for suicidal
ideation/behavior revealed that clinical staff completed the required SREs in only 83 percent (35
of 42) of the cases. Completion of SREs for inmates housed in alternative housing was also
audited. The sample review found that required SREs were completed in all (20 of 20) cases.
This reviewer examined a sample of 15 SREs from patients released from a MHCB between
April and July 2017. Most of the safety plans contained in the discharging SREs were not
adequate, with several written by the same clinician. The following safety plan was duplicated
by this clinician in at least three cases (NKSP 1, NKSP 2, and NKSP 6) examined by this
reviewer:
Processing material pertaining to coping with long sentence and finding meaning
to living effectively while incarcerated; increase functioning at a lower level of
care through stability of mood. I/P will be able to control and self-sooth when in
distress and will be able to name coping skills, e.g., walking away, taking deep
breaths, talking to clinicians, and know when to apply these strategies prior to
being placed in EOPS LOC. I/P is to be medication compliant 90% of the time.
CBT interventions to address coping skills and include psychoeducational on
importance of medication compliance and how to implement strategies that aid
with tolerance of distressful affect in a healthy manner.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.

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This reviewer was presented with documentation of 205 cases of patients discharged from a
MHCB or alternative housing placement that remained at NKSP and were not transferred to
administrative segregation (where observation at 30-minute intervals was required) from January
1, 2017 through June 30, 2017. The review found that only 75 percent had Page One of the
“Discharge Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental
health clinicians, with approximately 81 percent of the custody checks recommended for 48
hours or more by clinicians. In addition, only 85 percent of the “custody check” forms (Page
Two) were completed correctly by correctional staff at 30-minute intervals, with problems
related to gaps in documentation during both First and Third Watch.
Intervention: All toured housing units contained an emergency response bag that included a
micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (April through June
2017) found that quorums were not achieved in any of the meetings. However, it was
noteworthy that both the Warden and CEO were (not required members) active participants in
each of the meetings. The meeting minutes were otherwise unremarkable.
Training: According to training records, 100 percent of both custody and nursing staff were
currently certified in CPR. In addition, approximately 99 percent of custody staff, 97 percent of
medical staff, and 90 percent of mental health staff received annual suicide prevention block
training during 2016. Finally, as of June 2017, only 84 percent of mental health clinicians had
completed the SRE mentoring program, 100 percent had received the seven-hour SRE training,
and no clinicians were credited with completing safety plan training because adequate records
were not kept.
Recent Suicides: NKSP did not experience any inmate suicides during the review period.
7)

Richard J. Donovan Correctional Facility (RJD)

Inspection: July 25-26, 2017 (previous suicide prevention audit was on October 25-26, 2016).
RJD housed approximately 3,798 inmates at the time of the on-site assessment.
Screening/Assessment: This reviewer observed several new admissions during the intake
screening process in the R&R unit on July 25, 2017. The nurse’s office that was primarily
utilized for intake screening had been renovated and enlarged the previous year, and had a large
window to enhance visibility, as well as two options for egress. The nurse was observed to be
asking all of the required questions and entering the information on a hard copy of the Initial
Health Screening form. (Of note, RJD had not yet implemented EHRS at the time of the on-site
assessment.) During the screening process in the primary nurse’s office, the door remained
closed, with an officer stationed in an outer room which served as another nurse’s station. When
there were multiple inmates to be processed, as there was on July 25, this reviewer observed that
the outer room was also utilized to conduct intake screening. When both rooms were utilized,
this reviewer observed an officer escort a second inmate through the outer room into the primary
nurse’s office during the screening process, thus interrupting the screening and compromising
privacy and confidentiality. This practice could be corrected simply by requiring the escorting
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officer to bypass the outer room and walk through a short corridor that connects to the primary
nurse’s office.
Daily PT rounds in the B-6 and B-7 administrative segregation units were observed on July 25.
The rounds were unremarkable, and the PTs were observed to be correctly completing the Psych
Tech Daily Rounds Forms at cell-front on all caseload inmates.
Housing: RJD had 12 MHCBs, as well as two swing beds. All 14 rooms were suicide-resistant
and did not contain any obvious protrusions which could be used in a hanging suicide attempt.
Both administrative segregation units (B-6 and B-7) each contained 12 retrofitted new intake
cells. During inspection of each unit, this reviewer observed that all new intake inmates were
housed in new intake cells.
Finally, alternative housing to temporarily house inmates identified as suicidal and awaiting
MHCB placement was extensively used at RJD. Most inmates were placed in the B-7
administrative segregation unit (which was used for both 3CMS and general population) but
could also be housed in other designated locations. On July 25, there were approximately 12
inmates on alternative housing status in B-7. This reviewer was provided data that indicated 283
inmates were placed in alternative housing from April 6 through July 21, 2017. The vast
majority (74 percent) were housed over 24 hours, including approximately 29 percent held
between 25 and 47 hours, 25 percent over 48 hours, and 20 percent over 72 hours. All inmates
were observed to be provided bunks and observed on a continuous 1:1 basis. The overwhelming
majority (90 percent) of inmates housed in alternative housing were later placed in a MHCB.
The overall length of stay in alternative housing for these 283 inmates was 50 hours.
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCB unit. In addition, patients not on suicide observation status were observed at 15-minute
intervals by nursing staff. This reviewer was not able to verify the accuracy of observation
rounds because RJD had not yet implemented EHRS at the time of the on-site assessment.
This reviewer observed four IDTT meetings in the MHCB unit on July 26. The treatment team
was well represented by mental health, medical, and custody staff. Overall, there was very good
discussion in most cases regarding current suicide risk and safety planning for those patients
where SI was the primary concern.
A previous problem of non-suicidal patients not being given “full-issue” clothing had been
resolved following the previous assessment, and all patients were observed to be appropriately
clothed consistent with their level of suicide risk. This reviewer did not observe any problems
related to MHCB privileges, and observed a patient using the telephone during the inspection.
RJD continued to demonstrate a very proactive yard program within the MHCB unit that
included an enthusiastic full-time RT that tried to encourage patients to attend yard twice a week.
Music, books, magazines, and photocopies of daily newspapers continued to be available to
patients that attended yard.

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A review of Guard One data for a recent 24-hour period found a combined 98-percent
compliance in both B-6 and B-7 administrative segregation units with the required checks not
exceeding 35-minute intervals.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS for the period January 1 through
June 30, 2017. This reviewer’s subsequent sample eUHR review of 40 cases of emergency
mental health referrals for suicidal ideation/behavior found that clinicians completed the required
SREs in 93 percent (37 of 40) of the cases.
This reviewer examined a sample of ten SREs from patients released from a MHCB between
May through July 2017. Most contained an adequate safety plan for reducing SI. For example,
in one case (RJD 1), the safety plan stated the following:
D/C to EOP LOC. Start MH 5-day follow-up procedures. Add up to 10+ hours
of groups including life skills, conflict resolution and stress management. Add to
high risk list for at least 14 days to monitor for transition to ASU and to EOP.
Teach IP warning signs of stress (emotional, physical and psychological), as well
as coping skills for stress including breathing techniques/meditation, mindful
drawing, encourage singing, puzzles for distraction, SMART goal setting, and
techniques to manage worrying (such as create a ‘worry’ period). Teach coping
skills to reduce impulsivity to reduce future 115s such as counting, breathing or
distraction. Teach DBT distress tolerance skills to reduce possible distress from
receiving 115, such as positive self-talk, engaging in activities, or prayer.
Monitor and encourage regular contact with family/support system. Inmate has
already been referred and accepted to DSH-ICF for further support.
The challenge at RJD was that, although clinicians have continued to demonstrate adequate
safety planning, there were often problems with concordance between safety plans contained
within discharging SREs and safety plan summary sections contained within accompanying
Interdisciplinary Progress Note – 5-Day Follow-Up (CDCR MH-7230-B) forms. For example,
the safety plan contained on the first day of the 5-Day Follow-Up Progress Note for the above
case (RJD 1) stated the following:
MH staff will continue 4 more days of follow-up, or more, as needed. His dx now
is adjustment DO with depressed mood. He has no rx’d psychotropic meds now,
that several rx’d medical meds. He will continue taking them as rx’d and ask for
meds’ eval as needed. He will be monitored by CO staff hourly while in Ad Seg.
He will get and use a pencil and puzzles as distractions from his reported
boredom. He will ask for additional help as needed. He knows how to do so.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
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continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 208 cases of inmates discharged from a
MHCB or alternative housing placement that remained at RJD and were not transferred to
administrative segregation (where observation at 30-minute intervals was required) from January
1 through June 30, 2017. The review found that 78 percent had Page One of the “Discharge
Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental health clinicians,
with approximately 75 percent of the custody checks recommended for the full 72 hours of
observation. In addition, 89 percent of the “custody checks” forms (Page Two) were completed
correctly by correctional staff at 30-minute intervals, with problems related to gaps in
documentation.
Intervention: All housing units toured by this reviewer contained an emergency response bag
that included a micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes from April through
June 2017 found that quorums were achieved during April and May. In fact, the meetings
averaged between 19 and 27 participants each month. Meeting minutes included corrective
action plans from this reviewer’s previous assessment.
Training: According to training records, 100 percent of both custody and nursing staff were
currently certified in CPR. In addition, 100 percent of custody staff, 79 percent of medical staff,
and 93 percent of mental health staff received annual suicide prevention block training during
2016. Finally, as of June 2017, 97 percent of mental health clinicians had completed the SRE
mentoring program, 96 percent received the seven-hour SRE training, and 91 percent had
completed safety plan training.
Recent Suicides: RJD experienced one inmate suicide during the review period. In that case
(RJD 2), the inmate was found hanging from the top bunk by a sheet in his SNY cell during the
morning of May 3, 2017. The inmate entered the CDCR system in November 2001 to serve a
16- year-to-life sentence for second-degree murder (which occurred at age 16). He was
transferred to RJD in April 2015. The inmate incurred eight RVRs during his 16-year
incarceration, the most recent of which occurred in 2013 for possession of dangerous contraband.
He was not known to be gang-affiliated but was placed in SNY in July 2010 after incurring drug
debts. The inmate had good support from family, including from his girlfriend and mother, who
wrote letters to him several times per week and had regular telephone contact.
According to available records, the inmate had a dysfunctional childhood that included domestic
violence between his parents. His mother suffered from depression and had previously
attempted suicide. The inmate also experienced mental illness as a teenager, including
hospitalization on two occasions for anxiety and depression. Upon entry into CDCR in 2001, he
was periodically seen by mental health staff, but not placed in the MHSDS until August 2010 (at
3CMS). The inmate had been a victim of a stabbing a month earlier and began to have problems
with sleeping, poor appetite, and social withdrawal. He was initially diagnosed with Dysthymic
Disorder. During the next few years, the inmate continued to report depressed mood, anxiety,
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and chronic pain secondary to the stabbing. He also spent time preparing for his upcoming
parole hearing. In November 2015, the inmate appeared before the BPH and was denied parole
consideration for three years. Two months later on January 17, 2016, he was transferred to an
outside hospital following a drug overdose. Upon his return, documentation described his
thought process as “scattered, paranoid, and he reported suicidal ideation with a wish to die,
claiming he was severely depressed.” The inmate initially admitted, but subsequently denied,
that the overdose was a suicide attempt. (Previous records had also indicated that he attempted
suicide by overdose at age 16.) He was placed in a MHCB at CSP/Sac and continued to display
bizarre behavior. The inmate told a psychiatrist that he did not want to begin psychotropic
medication because he was preparing for another parole hearing and believed he “might not
parole if made EOP.”
The inmate was later discharged from the MHCB in February 2016 and returned to RJD with a
diagnosis of Psychotic Disorder Not Otherwise Specified (NOS) and Mood Disorder NOS, Ruleout Schizoaffective Disorder and Major Depressive Disorder, Recurrent with Psychotic Features,
Amphetamine and Opiate Abuse. Although prescribed psychotropic medication, the inmate
refused to take it. He continued to exhibit bizarre and delusional behavior, culminating in a
detailed letter to the FBI in which he alleged that a mind control machine had been stolen from a
local FBI office and placed on the grounds of RJD. A recommendation to increase the inmate’s
level of care to EOP was considered, but ultimately rejected by the IDTT, citing that he remained
able to maintain normal programming on the 3CMS yard.
The inmate last met with his PC on February 16, 2017, with the clinician noting that he had been
stable and working on self-help packets. The progress note stated that the plan was to continue
treatment at 3CMS level of care and consider removal from MHSDS at the next IDTT if the
inmate remained stable without medication, but, according to the CDCR reviewer in this case,
“In terms of meeting treatment goals, the inmate’s progress was mixed at best. Although he did
complete several take-home packets on self-help topics, including substance abuse, and did not
attend/complete substance abuse groups, there was minimal evidence in the PC’s documentation
regarding any interventions to address his delusional thought process. Instead, the PC opined ‘it
is probably counterproductive to confront his delusional thinking.’”
The CDCR reviewer did not find any specific precipitating factors that were known to staff
indicating that the inmate was contemplating suicide, and although he continued to suffer chronic
abdominal pain sustained from the 2010 stabbing, this medical issue was not viewed as a
proximate cause of his death. Posthumously reviewed telephone conversations between the
inmate and his mother and girlfriend offered contrasting indications of his behavior. For
example, in January and February 2017, the inmate often expressed suicidal ideation and
hopelessness during the telephone calls, whereas during April 2017, “his affect was calm and he
did not seem to be stressed or agitated, and there was minimal evidence of delusional thought
content” or suicidal ideation. Of note, however, the inmate postponed his parole hearing on
April 3 and updated his Death Notification list to include both his mother and sister on May 1,
two days before his death. The CDCR reviewer concluded that:
It is not known why he chose to end his life, as he was actively making plans for
the future; this included completing self-help treatment, making arrangements for
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transitional housing, and arranging active employment opportunities. However,
he also had absolutely no insight into his mental illness and did not actively use
mental health services or psychotropic medication in a way that would actually
benefit him. He believed mental illness was a stigma that would follow him and
hinder his ability to be released from prison, which is a large part of why he
refused psychiatric medication. Based on telephone calls recovered postmortem,
it is likely the inmate’s mother consulted with his attorney and shared her
concerns about his delusional system and current mental state, which may have
prompted his waiving his right to appear at the BPH scheduled for May 2017.
What remains unclear is why the information about his suicidal thinking and
psychiatric decompensation was not shared with the prison’s mental health staff.
The Suicide Report contained seven recommendations for corrective action through a QIP:
1) Activation of the Emergency Medical System (calling 911) did not take place
until approximately 10 minutes into the emergency which cause a significant
delay in appropriate medical response. IMS P&P Chapter 12: Emergency Medical
Response Instructions indicate that ‘All Staff Have the Authority to Initiate a 911
Call for Emergency Medical Services (EMS).’
2) The documentation surrounding treatment planning on September 8, 2016 at
RJD and treatment outcomes was insufficient and problematic.
3) The SRE completed on January 17, 2016 at RJD contained several errors and
did not accurately incorporate chronic and acute risk factors. As a result, the
formulation of risk appeared to have been underestimated.
4) HQ: A final post MHCB discharge SRE was due in February 2017. This SRE
did not occur due to a due dates error so that clinician was unaware that an SRE
was due at that time.
5) The SRE completed for the inmate at SAC on February 16, 2016 upon
discharge from MHCB also did not accurately reflect true chronic and acute risk
factors. Additionally, there were multiple concerns with the documented
safety/risk reduction plan.
6) There was no mental health progress note from SAC on February 13, 2016
found in the eUHR chart, or data entry in MHTS reflecting a contact for that date.
Per MHSDS Program Guide, Chapter 5 (15-5-13): In MHCB, “an inmatepatient’s condition shall be assessed and monitored daily by the treating clinician,
either a psychiatrist or a psychologist.”
7) The inmate did not seek appropriate mental health treatment due to a
misconception that his mental health issues might negatively impact his possible
release from prison.

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8)

California Health Care Facility (CHCF)

Inspection: August 8-9, 2017 (previous suicide prevention audit was on September 1-2, 2016).
CHCF housed approximately 2,385 inmates at the time of the on-site assessment.
Screening/Assessment: The intake screening process within the R&R unit was not observed
because there were not any new inmates admitted into the facility during the two-day
assessment. Due to a scheduling conflict, daily PT rounds in the administrative segregation unit
could not be observed during the on-site assessment.
Housing: CHCF had 98 MHCBs in housing units A1A, A1B, and A2B. All were suicideresistant and did not contain any obvious protrusions which could be used in a hanging suicide
attempt. The administrative segregation unit had eight retrofitted suicide-resistant cells
designated for new intake inmates. During the inspection, this reviewer observed that all new
intake inmates were housed in new intake cells.
Finally, alternative housing cells to temporarily house inmates identified as suicidal and
awaiting MHCB placement were used on almost a daily basis at CHCF. Various units were
utilized for alternative housing, including, but not limited to, D1A, D1B, 3CA, and E1A. Each
inmate was provided a stack-a-bunk (when not assigned to a cell with a pre-existing bunk) and
observed on a continuous 1:1 basis. From May 1 through July 30, 2017, there were
approximately 101 inmates placed in alternative housing, and the vast majority (81 percent) was
released within 24 hours. Few inmates were held in alternative housing over 48 hours. Most
were subsequently placed in a MHCB. This reviewer also sampled 13 cases and verified that
each had required a SRE/SRASHE completed, an improvement from the previous assessment
when only 70 percent of SREs were completed. The overall length of stay in alternative housing
for these 101 inmates was 19 hours.
Observation: Both Suicide Precaution and Suicide Watch statuses were being used in the
MHCB units. In addition, patients not on suicide observation status were observed at 15-minute
intervals by nursing staff. This reviewer subsequently verified the accuracy of observation
rounds by reviewing the EHRS charts of six patients (CHCF 1, CHCF 2, CHCF 3, CHCF 4,
CHCF 5, and CHCF 6) on Suicide Precaution status in the three MHCB units during an eighthour period from 12:00 a.m. through 7:59 a.m. on August 8, 2017. The chart review found
numerous observation checks (i.e., between eight and 13 per patient) that were in excess of
required 15-minute intervals, with the longest gap between checks being 42 minutes in one case
(CHCF 2). The following case (CHCF 4) exemplified the significance of the problem: There
were 11 violations of 23-, 16-, 27-, 21-, 31-, 22-, 19-, 23-, 33-, 16-, and 16-minute gaps between
the required 15-minute intervals. Violations in the four cases were by multiple nursing staff in
all three MHCB units. Of note, similar deficiencies in observation rounds by nursing staff were
found during the previous assessment when handwritten Suicide Watch/Suicide Precaution
Record observation forms were used.
During this reviewer’s previous assessment in 2016, numerous deficiencies were observed
during the IDTT team meetings in all three MHCB units, including the quality of discussion
regarding each patient’s current observation level and safety planning, confusion regarding
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clothing and privilege allowance, and standing orders for Suicide Precaution status at ten-day
intervals. This on-site assessment found significant improvement. This reviewer observed eight
IDTT meetings in all three MHCB units on August 8-9. All of the observed IDTTs were well
represented by custody, medical, and mental health staff. (RTs were not represented only
because they were conducting groups at the time of the meetings.) Three of the eight IDTT
meetings involved patients who were being discharged from the MHCB, and two of the three
cases included an adequate discussion of safety planning for reducing SI. With one exception
involving a team decision not to allow a patient whose mother died two weeks earlier a telephone
call because “maximum custody precludes telephone use,” there was good use of both clothing
and privilege allowance privileges. In addition, standing orders for Suicide Precaution status at
ten-day intervals were not found in any of the reviewed charts.
A review of Guard One data for a recent 24-hour period in the administrative segregation unit
found 98-percent compliance with required checks that did not exceed 35-minute intervals.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS from January 1 through July 31,
2017. This reviewer’s sample EHRS review of 40 cases of emergency mental health referrals for
suicidal ideation/behavior found that clinicians completed the required SREs in 93 percent (37 of
40) of the cases. This was an improvement from the previous assessment when only 84 percent
of SREs were completed.
This reviewer examined a sample of ten SREs from patients released from a MHCB between
June and July 2017. Most of the safety plans to reduce SI in each SRE were very problematic.
For example, the safety plan for a patient (CHCF 7) who had been placed in a MHCB for ten
days was the following:
Discharge to EOP; needs assistance to live in a dorm setting as a level II inmate,
may have a diagnosable anxiety disorder; Initiate 5-day follow-up upon return to
EOP.
The safety plan for another patient (CHCF 8) simply summarized Program Guide requirements
(as well as misinterpreted other policies):
1) Patient will be placed on a 30-day Alert (for hoarding prescription meds) and
monitor for any signs of OD
2) Patient will be returned to MHCB should he engage in or give any indications
of SI, intent, plan
3) Patient will be discharged with a 30-day supply of mental health medications
4) Patient will be placed on a 5-day Suicide Precaution/Watch at sending
institution to ensure patient stability
5) Patient will be seen by his PC x 1 per week at EOP LOC
6) Patient will participate and structured therapeutic groups x 10 per/week
7) Patient will be seen by psychiatry for medication monitoring and follow-up
treatment

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Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 77 cases of patients discharged from a
MHCB or alternative housing placement that remained at CHCF and were not transferred to
administrative segregation (where observation at 30-minute intervals was required) from January
through June 2017. The review found that only 42 percent had Page One of the “Discharge
Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental health clinicians,
with most of the custody checks recommended for only 24 hours by clinicians. In addition, only
62 percent of the “custody check” forms (Page Two) were completed correctly by correctional
staff at 30-minute intervals. Most of the problems were related to clinicians either not initiating
the 7497 process or failing to sign the forms which authorized discontinuation of the checks, and
correctional officers either conducting checks at 60-minute intervals or failing to conduct checks
for significant amounts of time.
Intervention: All toured housing units contained an emergency response bag that included a
micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (May through July
2017) found that quorums were reached in only one month (July). This reviewer was presented
with recent memorandums from both the SPRFIT coordinator and CMH regarding corrective
action plans from this reviewer’s previous assessment. Meeting minutes were otherwise
unremarkable.
Training: According to training records, 98 percent of custody staff and 100 percent of medical
staff were currently certified in CPR. In addition, 93 percent of custody staff, 98 percent of
medical staff, and only 86 percent of mental health staff received annual suicide prevention
block training during 2016. Finally, as of July 2017, 87 percent of mental health clinicians had
completed the SRE mentoring program, 90 percent had received the seven-hour SRE training,
and only 80 percent had completed safety plan training.
Recent Suicides: CHCF did not experience any inmate suicides during the review period.
9)

Mule Creek State Prison (MCSP)

Inspection: August 10-11, 2017 (previous suicide prevention audit was on September 27-28,
2016). MCSP housed approximately 3,619 inmates at the time of the on-site assessment.
Screening/Assessment: This reviewer observed a few new admissions during the intake
screening process in the R&R unit on August 10. The nurse was observed to be asking all of the
required questions and entering the information on a hard copy of the Initial Health Screening
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form. (Of note, MCSP had not yet implemented EHRS at the time of the on-site assessment.)
The door to the new nurse’s office was closed, with the officer stationed outside providing
security.
In addition, this reviewer observed daily PT rounds in the administrative segregation units
(Buildings 12 and 13) on August 11. The rounds were unremarkable, and the PTs correctly
completed a hard copy of the Psych Tech Daily Rounds Form at cell-front for all caseload
inmates.
Housing: MCSP had a ten-bed CTC, with eight designated MHCBs that were suicide-resistant
and not containing any obvious protrusions which could be utilized in a hanging suicide attempt.
Further, Building 12 (housing mostly administrative segregation EOP and some 3CMS inmates)
had approximately 30 retrofitted suicide-resistant cells designated for new intake inmates, an
increase of 14 new intake cells from the previous assessment. During inspection of this unit, all
new intake inmates were appropriately housed in new intake cells, a significant improvement
from several previous assessments. Building 13 (housing both administrative segregation 3CMS
and general population inmates) no longer was utilized for new intake.
Finally, alternative housing cells to temporarily house inmates identified as suicidal and
awaiting MHCB placement were primarily found in Building 13, as well as other designated
locations. Alternative housing was used on a daily basis at MCSP, and inmates were all
furnished beds and observed on a 1:1 basis. From May 1 through July 31, 2017, there were
approximately 154 inmates placed in alternative housing, and the overwhelming majority (94
percent) were released within 24 hours. The overall length of stay in alternative housing for
these 154 inmates was 14 hours.
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCB. In addition, patients not on suicide observation status were required to be observed at
30-minute intervals by nursing staff. At the time of the on-site assessment, MCSP had not yet
implemented EHRS, and nursing staff were still utilizing Suicide Watch/Suicide Precaution
Record forms to document the observation of patients on suicide observation status. Observation
of MHCB patients was problematic. At approximately 8:08 a.m. on August 11, 2017, a
colleague of this reviewer arrived at the MHCB and reviewed the Suicide Watch/Suicide
Precaution Record forms of five patients (MCSP 1, MCSP 2, MCSP 3, MCSP 4, and MCSP 5)
who were required to be observed at either 30-minute (MCSP 1 through MCSP 4) or 15-minute
intervals (MCSP 5). Each observation form was located on the door of each MHCB room. The
initial review at 8:08 a.m. found the last documented check for MCSP 1 had been at 6:50 a.m., a
period of 78 minutes. The last documented check for MCSP 2, MCSP 3, and MCSP 4 had been
at 7:20 a.m., a period of 48 minutes. The last documented check for MCSP 5, who was on
Suicide Precaution status, was at 7:22 a.m., a period of 46 minutes. As this reviewer’s colleague
was exiting the MHCB unit at approximately 8:35 a.m., the same five Suicide Watch/Suicide
Precaution Record forms were again reviewed and found to have been falsified with notations
suggesting that checks were performed at 8:00 a.m. Similar problems with the correct
documentation of observation rounds were also found during this reviewer’s two previous
assessments.

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A previous problem of MHCB patients having to choose between an out-of-room activity of
either yard or the program office had been corrected. An RT was assigned to the MHCB unit for
40 hours a week and utilized both the program office and yard for out-of-room activities. In
addition, documentation indicated that patients were being offered both telephone and visiting
privileges following their first IDTT meeting.
Three IDTT meetings were observed in the MHCB unit on August 10. The meetings were well
attended by custody, medical, and mental health personnel. Two of the IDTTs involved complex
cases in which safety planning was either not relevant or appropriate for discussion. The third
case (MCSP 6), however, involved a patient who was admitted eight days earlier for suicidal
ideation and grave disability, and the treatment team decided to discharge the patient without any
discussion of a safety plan to reduce SI. The patient’s subsequent discharging SRE dated August
10 contained the following safety plan that was not discussed during the IDTT:
1) IP should be closely monitored. IP is currently medication compliant and
appears to have good insight to his medication needs.
2) IP was given a “coping card” to help remind him of coping skills he can use
when he becomes upset. EOP PC should work with IP on expanding items on this
card.
3) IP enjoys recreation activities both in and out of cell to help distract IP from
negative thoughts/activity. EOP team should work with IP on expanding
activities/protective factors.
4) IP has a long hx of trauma and substance abuse that he would benefit from
processing in therapy sessions.
Protective factors that mitigate risk include: family support-mother, hobbies
(reading, writing, coloring, music), some insight, and is motivated for treatment.
Finally, a review of Guard One data for a recent 24-hour period in the administrative segregation
units found almost 100-percent compliance with required checks that did not exceed 35-minute
intervals.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS for the period of February 1 through
July 31, 2017. A subsequent sample eUHR review of 40 cases of emergency mental health
referrals for suicidal ideation/behavior found that clinicians completed the required SREs in 95
percent (38 of 40) of cases.
This reviewer examined a sample of ten SREs for patients released from the MHCB between
May and July 2017. In sum, although there were improvements from prior assessments in efforts
to develop adequate safety plans, as well as examples of more consistent safety plan summaries
contained within accompanying Interdisciplinary Progress Note – 5-Day Follow-Up (CDCR
MH-7230-B) forms, such efforts were collectively uneven in the sample documentation. For
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example, the first day Interdisciplinary Progress Note – 5-Day Follow-Up (CDCR MH-7230-B)
form for the above referenced case (MCSP 6), dated August 11, stated the following:
IP stated he knows he can contact custody staff if he feels he may harm himself.
He was informed that his IDTT was probably going to be next week Thursday.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 254 cases of inmates discharged from a
MHCB or alternative housing placement that remained at MCSP and were not transferred to
administrative segregation (where observation at 30-minute intervals was required) from January
1 through July 31, 2017. The review found that only 45 percent had Page One of the “Discharge
Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental health clinicians,
with most custody checks recommended for only 24 hours by clinicians. In addition, 85 percent
of the “custody check” forms (Page Two) were completed correctly by correctional staff at 30minute intervals. Problems found related to clinicians discontinuing the checks in less than the
required 24 hours or failing to sign the forms which authorized discontinuation of the checks at
24 hours, and correctional officers failing to conduct checks for significant amounts of time.
Intervention: All housing units toured by this reviewer contained an emergency response bag
that included a micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (April through June
2017) found that quorums were not achieved in any of the meetings. Meeting minutes reflected
reference to corrective action plans in response to this reviewer’s previous assessment and were
otherwise unremarkable.
Training: According to training records, 99 percent of custody staff and 94 percent of nursing
staff were currently certified in CPR. In addition, 100 percent of custody staff, 96 percent of
medical staff, and 97 percent of mental health staff received annual suicide prevention block
training during 2016. Finally, as of July 2017, 100 percent of mental health clinicians had
completed the SRE mentoring program, 100 percent had received the seven-hour SRE training,
and 96 percent had completed the safety plan training.
Recent Suicides: MCSP experienced two inmate suicides during the review period. In the first
case (MCSP 7), the inmate was found exsanguinated in his SNY cell during the late morning of
June 28, 2017. He had entered the CDCR system (for a fifth term) on June 6, 2013 to serve a 98year-to-life sentence for two counts of attempted robbery and dissuading a witness. The inmate
was transferred to MCSP on June 26, 2015. He was subsequently placed in SNY for safety
concerns relating to both drug debt and being a gang dropout. The inmate had two RVRs during
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his confinement, the most recent of which occurred on March 29, 2017 and involved possession
of alcohol. He had been married for 34 years and had four children and five grandchildren. The
inmate had some family support, including irregular telephone calls with his wife and one
daughter, but such calls ended approximately one week before his suicide.
According to available records, the inmate had a very traumatic childhood that included both
physical and sexual abuse, as well as neglect. He was raised by a grandparent but became
involved with both substance abuse and the criminal justice system at age 12. The inmate
received mental health treatment during most of his earlier CDCR terms, and generally treated
for depressive symptoms, mood swings, anger, and impulsivity. His diagnoses included
Depressive Disorder NOS, Major Depressive Disorder, Recurrent and Bipolar Disorder. Prior
CDCR terms also included multiple MHCB and Department of State Hospitals (DSH)
placements. During his most recent confinement, the inmate was placed in a DSH-Acute
Psychiatric Program (APP) from February through May 2014, followed by Intermediate Care
Facility (ICF) treatment from May 2014 through June 2015 when he returned to MCSP at the
EOP LOC. He remained in EOP until his death, with final diagnoses of Major Depressive
Disorder, Recurrent, Moderate/ Mild, Polysubstance Dependence, in remission in a controlled
environment, Borderline Personality Disorder, and Antisocial Personality Disorder.
The inmate had a significant history of suicidal behavior, which included a suicide attempt at age
15 when he attempted to shoot himself with a gun. At least five other suicide attempts occurred
in the community and included cutting himself on the wrist, hanging himself in his home, and
multiple medication overdoses. There were also unconfirmed reports of a suicide attempt by
hanging in the county jail in 1996, as well as a serious suicide attempt at CSATF in February
2014 by severely lacerating himself on the neck, resulting in MHCB placement. The inmate’s
most recent SRE (dated January 19, 2017) assessed both his chronic and acute risk for suicide as
being “moderate.” Although placed on the MCSP’s “High Risk List,” such placement did not
result in an increase in the frequency of mental health services.
Although the inmate had several medical problems, including a seizure disorder, Hepatitis C, and
chronic neck and shoulder pain, these issues were not viewed by the CDCR reviewer in this case
to be contributory to the suicide. However, the reviewer found several probable precipitants to
the suicide, including notification to the inmate in December 2016 that some of his pain
medication was being discontinued, notification from his wife in April 2017 that she was filing
for divorce, and a brief telephone call with his daughter in mid-June 2017 when she informed
him not to call anymore. According to the CDCR reviewer, “As he was closest to his estranged
wife and daughter, their abandonment was likely paramount to his decision to end his life. He
freely admitted that feelings of rejection had spurred prior suicidal attempts; it is a plausible
conclusion this perceived abandonment on the part of his family coupled with illicit substance
use, hopelessness over his life-term, and ongoing physical pain likely triggered his suicide.”
The Suicide Report contained seven recommendations for corrective action through a QIP:
1) The primary clinician’s weekly documentation in the form of SOAPE notes is
problematic. Although the subjective and objective sections were properly
updated weekly, the assessment, plan, and education sections were not
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consistently updated after each submission. Rather, the assessment section
contained only a diagnosis without an appropriate clinical assessment/evaluation
of the presentation. Additionally, an overall review of the prior six months of
weekly documentation showed almost no change in the plan and education
sections, thus making it difficult to track what was being addressed in treatment,
what interventions were being used, and the inmate’s progress.
2) The SRE completed on January 19, 2017 is problematic as the PC checked 14
of 16 boxes under chronic risk, noted five previous serious suicide attempts, yet
only found the inmate to have moderate chronic risk. The justification for
choosing moderate risk (as opposed to high chronic) was not well developed on
the second page, except to say that moderate risk was chosen due to his sentence
and prior lethal suicide attempt in the past. Further, the safety/risk reduction plan
section was underdeveloped and did not accurately incorporate his specific risk
factors (which had led to prior attempts); these risk factors included perceived (or
actual) abandonment by family members, substance use, and life-term without
likelihood for parole.
3) The overall estimation of the inmate’s suicide risk appears to have been
underestimated given the early onset and severity of his prior suicide attempts.
Despite this underestimation of risk, the inmate was placed on the High Risk List
for suicide……a high risk log is to be maintained and presented for discussion by
the SPRFIT; however, the LOP does not speak to the procedures and function of
the HRL. It is unclear if his placement on this list provided additional resources
or monitoring beyond his EOP LOC.
4) It is unclear why the inmate was not elevated for a higher LOC over the last
three to six months of his life secondary to increase reports of SI, decreased
programming, divorce papers resulting in feelings of abandonment, and possible
reemergence of substance abuse.
5) On June 22, 2017, the inmate met with his PC and reported having “suicidal
thoughts and morbid thinking,” however a SRE was not provided. Per the Mental
Health Services Delivery System Program Guide, Chapter (12-10-8), “When an
inmate expresses current suicidal ideation, or make threats or attempts, a suicide
risk assessment shall be made by collecting, analyzing, and documenting data.
Documentation is achieved by conducting a standardized suicide risk evaluation
SRE. Further, when an inmate expresses chronic suicidal ideation without intent
or plan, the clinician may document that no change in suicide risk has occurred
since completion of the prior SRE, instead of completing a new SRE. In this
instant, the inmate reported suicidal thoughts, and although he denied current
intent or plan, there was no documentation in this note to indicate a SRE was
considered or a more thorough suicide risk assessment was completed on this
date. Additionally, the clinician did not document whether a specific change and
suicide risk had occurred since the prior SRE had been completed in January
2017.
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6) The SRE completed at SATF in February 2014, following a serious suicide
attempt, was poorly completed. Multiple boxes in the various sections were left
unchecked, and there were no details about the attempt, no mental status
examination listed, no real estimation or justification of risk (outside of ‘cut self
using a razor - feels hopeless and helpless’), and minimal safety plan (‘MHCB
placement, minimize escalation’). Although this SRE was conducted in 2014, it
is being identified as a concern due to the absence of critical information after a
serious suicide attempt, and to alert SATF to review current SRE quality and
procedures to ensure this issue has been remedied.
7) Activation of EMS (911) – (Custody and Nursing): On June 28, 2015, officer
immediately observes the inmate unresponsive and covered in blood on the lower
bunk. The officer immediately called a Code 1 medical response via institutional
radio to Building 6, Cell 202, and requests the medical cart. At 1121 hours, TTA
staff calls for an ambulance - a 6-minute delay in activation of 911…. Local
Operations Plan consistent with the memorandum identified above should be
established and readily available to ensure all staff is aware it is their
responsibility to initiate a 911 call during a medical emergency.
In the second case (MCSP 8), the inmate was found hanging from the upper bunk in his EOP cell
by a sheet during the morning of September 20, 2017. The inmate entered the CDCR system for
a second term in October 2009 to serve a 92-year-to-life sentence for attempted murder,
inflicting great bodily harm involving domestic violence, assault with a deadly weapon, terrorist
threat, and rape with force (of his girlfriend). He was transferred to MCSP in June 2017. The
inmate had only one RVR during his eight-year confinement, occurring in April 2011 for
possession of inmate manufactured alcohol. He was not known to be gang-affiliated. The
inmate did not have any family support during his most recent CDCR confinement, and there
was no record of either telephone calls or visits.
According to available information, the inmate, along with his brother and half-sister, was raised
by both parents. His father was an alcoholic and died as a result of his excessive drinking. The
inmate self-reported that he was a high school graduate, and also earned multiple undergraduate
and graduate college degrees. He also reported being gainfully employed from 1970 through
1999 and worked in the environmental engineering field. The inmate was married three times
and had a daughter with his third wife. That marriage was dissolved in 2006. He served in the
Army from 1974 through 1976 and was deployed to Vietnam where he was the sole survivor of a
helicopter crash which resulted in a coma for several days and numerous severe injuries. In
1991, he was diagnosed with depression, but was non-compliant with medication. The inmate
would also later be diagnosed with Personality Disorder NOS with narcissistic and antisocial
features, therefore, his education and employment histories would become suspect. The inmate
began drinking alcohol at age 18 and described himself as a “functional alcoholic” as an adult.
He did not have a juvenile arrest record, and his first involvement in the criminal justice system
occurred in 2000 when he was arrested and subsequently sentenced for attempted murder. He
served approximately eight years in CDCR, paroling in April 2008. He committed the instant
offense the following month.
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The inmate had a significant history of mental illness. In addition to previously being diagnosed
with depression and treated for alcoholism on three occasions in the community, the inmate was
placed in the MHSDS at the 3CMS level of care shortly after entering CDCR in November 2009.
From April through July 2010, he was placed in DSH following a suicide attempt at RJD in
March 2010. He was later elevated to EOP with a diagnosis of Mood Disorder NOS, Alcohol
Dependence, and Personality Disorder NOS, with narcissistic and antisocial features. In April
2015, a diagnosis of Post-Traumatic Stress Disorder (PTSD) was added. During his IDTT
meeting on May 5, 2016, the inmate reported that EOP is “what is keeping me alive at this
point.” The trauma treatment targeted his night terrors/nightmares, along with other PTSD
symptoms. His most recent diagnoses were PTSD, chronic (provisional), Major Depressive
Disorder, Recurrent, Moderate (provisional), and R/O Bipolar II, Depressed. Other than the
suicide attempt at RJD in 2010, the inmate reported only one other suicide attempt by drug
overdose while confined in the county jail. Although reporting ongoing, typically passive
suicidal ideation throughout his confinement, the inmate denied any plan or intention of
committing suicide. His last SRE, date unknown, listed his chronic risk for suicide as “high” and
acute risk as “low.”
The inmate last met with his psychiatrist on August 29, 2017 and while previously generally
non-compliant with medication, due to an increase in nightmares, he agreed to restart some of
the medication.
The inmate had significant medical problems including, but not limited to, emphysema, coronary
artery disease, benign prostate hypertrophy, lower back pain, and suspected colon cancer. He
was in the Disability Placement Program because of his mobility impairment and was issued
Double Medical Equipment that included a back-brace support, cane, eyeglasses, oxygen
concentrator, and walker. Due to his medical and mental health issues, the inmate was
continuously arguing against both dorm and double-cell status and insisted on single-cell
placement. (Of note, the inmate was removed from single-cell status sometime in July 2017 and
temporarily had a cellmate but was housed alone at the time of his death.)
The CDCR reviewer in this case did not note any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, simply stating that “From the
beginning of his incarceration, he maintained that death was preferable to life in prison.
Although he did not make another suicide attempt, he continued to express suicidal ideation,
generally passive in nature, throughout his incarceration until his death on September 20, 2017
by suicide.”
The Suicide Report contained seven recommendations for corrective action through a QIP:
1) SVSP IDTTs were not held in January and July 2016 according to timelines.
The Mental Health Program Guide, 2009 revision, states IDTTs for EOP
participants are to be held every 90 days unless the patient is on a modified
program, which requires an IDTT every 30 days.

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2) Treatment plans completed at SVSP outlined the inmate’s ongoing suicidal
ideation, combined with depressive and PTSD symptoms with corresponding
goals and treatment interventions. The recommendation for single cell status was
documented. However, when the inmate transferred to MCSP, his treatment plan
on August 1, 2017 omitted goals or interventions to address suicidal ideation. No
rationale for this omission was documented.
3) At MCSP, the mental health screening did not acknowledge the long history of
suicidal ideation and therefore did not prompt completion of an SRE upon his
arrival. Mental health screening upon intake requires a thorough review of the
mental health records.
4) At SVSP, psychiatric appointments were not scheduled according to timelines
in July 2015, December 2015, May 2016, July and August 2016, and November
and December 2016. Policy requires psychiatric appointments every 30 days or
more frequently as needed.
5) The inmate’s last three primary clinician visits were conducted cell front
without a confidential setting being offered and declined. Meetings with patients
are required to at least be offered a confidential setting.
6) Primary clinician appointments did not occur in accordance with policy. There
was a missed primary clinician appointment in the weeks preceding his death. He
was seen on September 1, 2017 and not seen again until September 12, 2017.
7) Multiple reports indicate when the inmate was cut down he fell backward
striking his head on the stool in the cell, then striking his head on the cell floor. It
should be noted that staff should do everything possible to try and relieve the
pressure/inmate’s weight when cutting down an inmate and support them to the
ground.
10)

California State Prison-Solano (CSP/Solano)

Inspection: August 23-24, 2017 (previous suicide prevention audit was on May 26-27, 2016).
CSP/Solano housed approximately 3,742 inmates at the time of the on-site assessment.
Screening/Assessment: This reviewer observed a few new admissions during the intake
screening process in the R&R unit on August 24. The nurse was observed to be asking all of the
questions and correctly entering the information into the EHRS. The nurse’s office door was
closed during the process, thus ensuring both privacy and confidentiality.
Daily PT rounds in administrative segregation (Building 10) were observed on August 23. The
rounds were unremarkable, and the PT was observed to be correctly entering Psych Tech Daily
Rounds information into the EHRS for each caseload inmate.

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Housing: CSP/Solano had nine MHCBs; each room was suicide-resistant and did not contain
any obvious protrusions which could be used in a suicide attempt by hanging.
The administrative segregation unit (Building 10) contained a total of eight retrofitted new intake
cells, with two additional cells renovated since the previous assessment. This reviewer observed
that all new intake inmates were housed in new intake cells as required. However, it should be
noted that many of the exterior cell windows still contained frosted screening that obscured
natural light into the cell. CDCR headquarters had ordered that such screening be removed in
2015. The project had commenced on August 1, 2018 and was still ongoing during this on-site
assessment.
Finally, alternative housing cells to temporarily house inmates identified as suicidal and
awaiting MHCB placement was primarily found in Building 10 and continued to be used
infrequently at the facility. Because inmates were housed in the administrative segregation unit,
all were furnished with bunks and required to be observed on a 1:1 basis. From January 1
through July 31, 2017, only 29 inmates were placed in alternative housing, and the vast majority
(83 percent) were released within 24 hours. No inmates were held in alternative housing over 48
hours. The total length of stay in alternative housing for these 29 inmates was 12 hours. (A
sample review of EHRS charts for inmates held in alternative housing found that required
SRASHEs were completed in all cases.)
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCB unit. In addition, patients not on a suicide observation status were observed at 30-minute
intervals by nursing staff. This reviewer subsequently verified the accuracy of observation
rounds by reviewing the EHRS charts of four patients on Suicide Precaution status in the MHCB
unit during nine-hour periods from 12:00 a.m. through 8:59 a.m. on several sample days (i.e.,
August 19 for SOL 1, August 23 for SOL 2 and SOL 3, and August 15 for SOL 4). The chart
review found numerous observation checks (between eight and 15 per patient) that were in
excess of required 15-minute intervals, with the longest gap between checks being 115 minutes
in one case (SOL 4). The following case (SOL 1) exemplified the significance of the problem:
There were 13 violations of 20-, 19-, 41-, 19-, 22-, 34-, 33-, 26-, 17-, 22-, 86-, 27-, and 62minute gaps between the required 15-minute intervals. Violations in the four cases were by
multiple nursing staff during multiple days. Due to the significant number of large gaps for all
patients, this reviewer subsequently conversed with a nursing supervisor, as well as several CTC
nurses, regarding the findings. The nursing supervisor attempted to downplay the findings by
suggesting that there might have been equipment failures in laptop equipment used by nursing
staff and/or staff might have been performing the checks but the data was somehow not being
recorded in real time; whereas the three RNs acknowledged that because CNA and PT staff were
not assigned to the CTC, and because there were several medically-infirm patients in the unit, the
RNs were not always able to observe patients on Suicide Precaution status at 15-minute intervals
as required.
In addition, a previous problem with patients being clothed in safety smocks while being
observed at 30-minute intervals, as well as patients not always being offered out-of-room
activities and privileges, had not been corrected and was perhaps worsening. There were
multiple deficiencies.
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First, in one case observed during an IDTT meeting on August 23, a patient (SOL 1) on fullissue status and required to be observed at 30-minute intervals (i.e., not on a suicide observation
status) entered the room wearing a T-shirt, boxers, and a smock.
Second, the RT was only available to the CTC between ten and 16 hours per week. A review of
RT progress notes for the nine patients in the MHCB unit as of August 23, 2017 found that these
patients were in the CTC for a combined 110 days, and only interacted with the RT for ten of
those days. The CTC did not have a program office, and a TTM was recently installed in the
dayroom for “out-of-room” activities. There was no television or DVD player to play movies, or
a radio to play music. RT programming was limited to board games either cell-side or in the
TTM. This reviewer was informed that the RT rarely attended IDTT meetings.
Third, a review of records indicated that none of nine patients had been offered yard consistent
with CTC policy, and there was documentation for only three of the patients being offered yard
during their entire MHCB placement. The records also indicated that no patients had been out
into the yard for at least four days.
Fourth, custody staff reported that telephone and visiting privileges rarely occurred in the
MHCB unit.
Fifth, a review of records indicated that only four of nine patients had been offered showers
consistent with policy.
Four IDTT meetings were observed on August 23-24. Overall, with the exception of the RT,
treatment teams were well represented by mental health, medical, and custody staff. The IDTT
meetings were uneven, and the PCs in each case made decisions (e.g., clothing and RT
programming) with limited or no input from treatment team members. The two cases observed
on August 23 were particularly problematic. In the first case (SOL 3), the patient had been
admitted into the MHCB on August 15 for danger to self. He had an extensive history of selfinjurious behavior, and multiple MHCB and DSH admissions. The patient still expressed
suicidal ideation and was on Suicide Precaution status clothed in a smock. The treatment team
discussed a PIP referral but did not distinguish between APP and ICF. Despite the patient’s SI,
there was no discussion regarding safety planning for coping skills to reduce the ideation. The
patient was offered a shower for the first time since his admission eight days earlier.
In the second case (SOL 1), the patient had been admitted into the MHCB on August 15 for
suicidal ideation and auditory hallucinations. He was currently not on any suicide observation
status and was on full-issue status, but as indicated above, still clothed in a smock. The patient
had been generally uncooperative with treatment and had multiple prior MHCB and DSH
admissions. Unbeknownst to the PC, a psychiatrist had assessed the patient two days earlier on
August 21 and recommended that he be discharged back to the EOP program at the next IDTT
meeting (August 23). Despite being admitted into the MHCB eight days earlier, the PC told the
patient on August 23 that “we need to keep you a little bit longer and get to know you….Would
you be okay being released on Monday?” (i.e., an additional five days). There was no discussion
regarding safety planning to reduce SI and, following the meeting, this reviewer intervened in an
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attempt for the patient to receive his full-issue clothing, yard, shower, and books, none of which
he had received since entering the MHCB unit eight days earlier.
Finally, a review of Guard One data for a recent 24-hour period in administrative segregation
found 99-percent compliance with required checks that did not exceed 35-minute intervals.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS for the period of January 1 through
July 31, 2017. The TTA log for the same time period was also reviewed. This reviewer’s
sample EHRS review of 40 emergency referrals for suicidal ideation/behavior revealed that
clinical staff completed required SRASHEs in 98 percent (39 of 40) of the cases, a significant
improvement from the previous assessment when there was only 84-percent compliance.
This reviewer examined a sample of ten SRE/SRASHEs from patients released from a MHCB
from May through August 2017. The review found that although some safety plans contained
within the SRE/SRASHEs were adequate, many were problematic, including the case (SOL 5) of
a patient with a chronic risk for suicide rated as “moderate” based upon three suicide attempts in
CDCR custody during the past few years. Following a ten-day placement in the MHCB, the
safety plan contained within the discharging SRE/SRASHE dated May 23, 2017 stated the
following:
Pt. is currently stable and reports he is not suicidal. He is being discharged at
CCCMS LOC. The expectation is that he will be moved quickly as he is a Solano
inmate. In the event that he is retained overnight he will continue to receive 24hour nursing care, continued contact with clinicians and access to medical and
dental depts. Upon discharge he will be placed on 5-day follow-up with checks
by custody officers.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of only 22 cases of inmates discharged from a
MHCB or alternative housing placement that remained at CSP/Solano and were not transferred
to administrative segregation (where observation at 30-minute intervals was required) from
January 1 through August 23, 2017. The review found that only 45 percent had Page One of the
“Discharge Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental
health clinicians, with most custody checks recommended for 72 hours by clinicians. In
addition, only 32 percent of the “custody check” forms (Page Two) were completed correctly by
correctional staff at 30-minute intervals. Problems found related to clinicians discontinuing the
checks in less than the required 24 hours or failing to sign the forms which authorized

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discontinuation of the checks at 24 hours, and correctional officers conducting checks at 60minute, rather than the required 30-minute, intervals.
Intervention: All reviewed housing units contained an emergency response bag that included a
micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (April through June
2017) found that quorums were not achieved in any of the meetings. Meeting minutes reflected
reference to corrective action plans in response to this reviewer’s previous assessment and were
otherwise unremarkable and continued to be sparse.
Training: According to training records, 100 percent of both custody and nursing staff were
certified in CPR. In addition, 100 percent of custody staff, 91 percent of medical staff, and 92
percent of mental health staff received annual suicide prevention block training during 2016.
Finally, as of August 2017, 97 percent of mental health clinicians had completed the SRE
mentoring program, 87 percent had received the seven-hour SRE training, and 91 percent had
completed safety plan training.
Recent Suicides: CSP/Solano experienced one inmate suicide during the review period. In that
case (SOL 6), the inmate was found hanging from the top bunk by his pants in his GP cell during
the afternoon of March 19, 2017. The inmate entered the CDCR system on November 16, 2015
to serve a seven-year and eight-month sentence for robbery. He was transferred to CSP/Solano
in May 2016. The inmate incurred four RVRs during his confinement, the most recent of which
occurred on October 18, 2016 and involved disrespect of a GED teacher. The inmate was not
known to be gang-affiliated. He had strong family support that included weekly visits and daily
telephone calls with his wife, as well as letter correspondence with his mother and other friends.
The inmate also had a 2-year-old daughter.
According to limited available records, the inmate had a very dysfunctional childhood that began
by being born at CCWF to an incarcerated mother. His father was also incarcerated and
remained so for much of the inmate’s life. Although noted to be a poor historian, the inmate and
his twin sister were initially raised by a relative; he was sexually abused at age 11. The inmate
became a ward of the state at age 13 and was subsequently diagnosed with Anxiety Disorder
during placement in a group home. He also had a lengthy juvenile arrest record and was
incarcerated for much of his teenage years. He began abusing drugs at age 11, and also
attempted suicide by hanging that same year due to the sexual abuse he endured. The inmate
also reported that an uncle committed suicide.
Upon entry into CDCR, the inmate did not screen positive during the mental health screening
portion of the RC process and was not initially referred to the MHSDS. However, several
months later in July 2016, he was seen by a mental health clinician after complaining of
depression, irritability, and poor sleep. The inmate was initially diagnosed with Adjustment
Disorder. Due to several deficiencies attributable to poor documentation, the inmate was not
formally placed into the MHSDS until October 26, 2016 at 3CMS level of care. Although
prescribed medication, the inmate preferred to be treated with both individual and group therapy,
and psychotropic medication was subsequently discontinued. Apart from self-reporting a prior
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suicide attempt at age 11, the inmate never expressed any suicidal ideation during his CDCR
confinement. He was never provided with an SRE. The inmate was very active in mental health
treatment, education classes, and work assignments.
Apart from one significant event that occurred during visitation with his wife several hours
before his death, the CDCR reviewer in this case did not find any other specific precipitating
factors that were known to staff indicating that this inmate was contemplating suicide, and there
were no medical issues that were viewed as contributory to his death. Staff and other inmates
interviewed did not offer any possible precipitating factors that led to the inmate’s suicide, with
most interviewed inmates stating that he worked hard on his programming and was deeply
devoted to his wife and young daughter. Some of these inmates noted that he appeared very
anxious to use the telephone after a visit with his wife on the morning of March 19, 2017, the
day of his suicide.
According to the Investigative Services Unit (ISU) review of the suicide, there was an incident
that occurred during the March 19 visit which resulted in the inmate handing his wife his
wedding band. Staff in the visiting room reported to ISU that following the visit, the inmate
asked staff to call his wife back, so he could retrieve his wedding ring. However, his wife had
already exited the building. Later that same afternoon, the inmate telephoned his wife and,
according to ISU staff who posthumously listened to the conversation, “repeatedly asked why
she did not give the ring back to him prior to the end of the visit and asked that she return the
ring the following weekend. She repeatedly responded that she would not visit him the
following weekend but would return the ring at her next visit. As a conversation continued, he
angrily threatened, numerous times, to commit suicide if she did not return the ring the following
weekend.” He committed suicide a few hours later. As offered by the CDCR reviewer, “The act
of suicide appeared to be an impulsive response to the threat of his perceived dissolution of his
family life, as there were no warning signs or indications of suicidal thoughts or contemplation
prior to the day of his death.”
The Suicide Report contained five recommendations for corrective action through a QIP:
1) There was no formal evaluation of suicide risk (e.g., a CDCR 7447 Suicide
Risk Evaluation) conducted at the time of the initial intake evaluation on August
3, 2016, even though the clinician states an intention to complete an evaluation,
and the intake evaluation completed in the EHRS on November 2, 2016 does not
document an assessment of risk. A mention of a past suicide attempt and denial
of current ideation or intent does not equate to an evaluation of potential for
suicide. According to the 2009 MHSDS Program Guide, “The clinical
assessment shall include… Evaluation of suicide and violence potential (p. 12-38). Further the suicide and self-harm section of the EHRS initial intake was
incomplete.
2) Upon entering the CDCR, 7386 Mental Health Evaluation on August 3, 2016,
which noted the inmate was being placed in the MHSDS as CCCMS LOC, no
CDCR-128 MH3, Mental Health Placement Chrono, was completed, causing a
delay in his placement into the MHSDS until October 26, 2016. Per the 2009
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MHSDS Program Guide, “A 128 MH3 Mental Health Placement Chrono shall be
produced with every change in level of care” (p. 12-3-1).
3) There was no CDCR 7448 Informed Consent for Mental Health Care in the
record. According to the 2009 MHSDS Program Guide, “Clinicians are
responsible for informing inmate-patients of the limits of confidentiality, or
ensuring that prior documentation in the UHR indicates that this disclosure has
occurred prior to commencement of a clinical encounter. CDCR 7448, Informed
Consent for Mental Health Care shall be used for this purpose.”
4) All clinical documentation by the PC lacked clinical detail pertaining to the
inmate’s current mental health status, presenting concerns and relevant historical
information that would be necessary to conceptualize a clinical case, formulate a
diagnosis, and develop an individualized treatment plan. The PC failed to
document mental status in several clinical encounters, which is standard practice
for clinical care. Further, there was no clinical rationale for the diagnosis
assigned or a discussion regarding differential diagnoses, as required in the CDCR
7386 Mental Health Evaluation. Finally, the initial treatment plan developed by
the PC was not individualized and did not reflect treatment targeting the
symptoms reported by the inmate.
5) Although staff requested an ambulance be called at 1632 hours, activation of
the Emergency Medical System (Calling 911) did not take place until
approximate 50 minutes into the emergency, which caused a significant delay in
appropriate medical response….
11)

California State Prison - Corcoran (CSP/Corcoran)

Inspection: October 10-11, 2017 (previous suicide prevention audit was June 21-22, 2016).
CSP/Corcoran housed approximately 3,157 inmates at the time of the on-site assessment.
Screening/Assessment: This reviewer observed a few new admissions during the intake
screening process in the R&R unit on October 11. The nurse was observed to be asking all of the
required questions and entering the information on a hard copy of the Initial Health Screening
form. (Of note, CSP/Corcoran had not yet implemented EHRS at the time of the on-site
assessment.) Privacy and confidentiality, however, remained compromised because the
screening occurred with the door open and an officer posted inside the nurse’s office. The only
difference between the current assessment and the assessment conducted by this reviewer in June
2016 was that at a TTM had been placed in the hallway. However, for reasons that remained
unclear, the TTM was not being utilized for intake screening and its placement remained
unacceptable because it was still located in a non-confidential area of a hallway used by both
staff and inmates. A CAP for this issue had first been created in March 2016 and remained
unresolved. This issue could be resolved if the TTM was relocated inside the nurse’s office or
another room in the R&R unit and the door remained closed, with the officer posted outside.

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Daily PT rounds were observed in two (of four) administrative segregation units (EOP
administrative segregation and long-term restricted housing (LTRH)) on October 11. The rounds
were unremarkable, and the PTs correctly completed a hard copy of the Psych Tech Daily
Rounds Form at cell-front for all caseload inmates.
Housing: CSP/Corcoran had 24 MHCBs. A previously identified deficiency of MHCB rooms
with wall ventilation grates containing holes that were in excess of 3/16-inch diameter had not
been corrected.21
Further, another previously identified deficiency of selected new intake cells in two
administrative segregation units not being completely retrofitted as suicide-resistant was verified
as corrected during this assessment. There were six new intake cells (100-105) located in the
STRH and ten new intake cells (124 through 128; 224 through 228) located in the EOP
administrative segregation unit (3A04). During inspection of both of these units, all new intake
inmates were observed to be in new intake cells.
Finally, alternative housing cells to temporarily house inmates identified as suicidal and
awaiting MHCB placement were primarily found in four designated OHU cells and a 20-cell
section of the LTRH unit. All cells used for alternative housing had beds, with inmates in OHU
cells provided stack-a-bunks and required to be observed on a continuous 1:1 basis. Alternative
housing was used extensively at CSP/Corcoran. From July 1 through September 30, 2017, there
were approximately 431 inmates placed in alternative housing, with only 51 percent released
within 24 hours, 29 percent released within 48 hours, 18 percent released within 72 hours, and
the remaining two percent housed over 72 hours. The average length of stay in alternative
housing for these 431 inmates was 35 hours.
Observation: Both Suicide Precaution and Suicide Watch statuses were being used in the
MHCB unit. In addition, patients not on suicide observation status were observed at 30-minute
intervals by nursing staff. This reviewer was not able to verify the accuracy of observation
rounds because CSP/Corcoran had not yet “gone-live” with EHRS at the time of the on-site
assessment.
Further, a previous problem with patients remaining clothed in safety smocks after being
clinically approved for “full-issue” clothing, as well as patients not being timely approved for
yard privileges and/or being forced to choose between an out-of-room activity and yard, had not
been corrected. There were multiple deficiencies.

On January 25, 2018, the court ruled that “[w]ithin 14 days from the date of this order defendants shall show cause
in writing why the inadequate wall ventilation grates at CSP/Corcoran cannot be replaced within six months.” ECF
No. 5762 at 4. On February 7, 2018, defendants submitted a plan to the court which indicated that the project would
be completed within six months. ECF No. 5775. On February 22, 2018, defendants informed the Special Master
that the 24-bed MHCB unit at CSP/Corcoran would be temporarily closed and that the renovation would commence
by March 19, 2018, with estimated completion within three to four weeks. On April 24, 2018, defendants notified
the Special Master that the renovation project at CSP/Corcoran had been completed and that all MHCB unit beds
were reactivated on April 24, 2018.
21

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First, no patients on full-issue clothing status were issued either a uniform or shirts and pants
because such clothing was not available in the MHCB unit. As such, this reviewer was informed
by IDTT members that safety smocks were issued to each patient for “privacy.”
Second, review of Physician’s Orders (CDCR 7221) forms found multiple contradictory orders.
For example, it was not uncommon to see Orders that allowed for both issuance of a safety
smock and “partial-issue” (i.e., shorts and T-shirt); there were orders to disallow both yard and
telephone privileges without clinical justification for patients not on suicide observation status;
as well as incorrectly automatically denying yard privileges for patients on administrative
segregation status.
Third, there was only one RT assigned to the CTC for 24 MHCB patients, and that staff member
informed this reviewer that one of those days was reserved for OHU medical patients. As such,
the RT estimated that they were available to each MHCB patient for only one hour every three
days. Due to the limited schedule, patients approved for out-of-room activities must choose
either the program office or yard. This writer was also informed that the RT rarely attended
IDTT meetings.
Fourth, a review of 22 records of patients who had been in the MHCB unit for at least 72 hours
as of October 10, 2017 indicated that only seven had been approved for yard privileges. The
records included an additional seven patients on administrative segregation status, all of whom
had not been approved for yard. (This reviewer was informed that because of security concerns
regarding a low roof line in the MHCB yard, a procedure had been developed requiring patients
on maximum-security and administrative segregation status to be escorted to an administrative
segregation unit yard. In practice, however, this was found not to be occurring on a regular
basis.) In addition, non-administrative segregation patients were also not approved for telephone
privileges.
In sum, most of the above deficiencies were identified by this reviewer in the initial 2014
assessment and remained very problematic.
Three IDTT meetings were observed on August 10 between two treatment teams. Both fourmember IDTTs were comprised of a psychologist, psychiatrist, CC1, and PT. Of the three cases
presented, only one demonstrated an adequate discussion of safety planning to reduce SI.
Finally, a review of Guard One data for a recent 24-hour period found a combined 99-percent
compliance in the four administrative segregation units (GP, STRH, LTRH, and EOP) with
required checks not exceeding 35-minute intervals.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS for the period July 1 through
October 10, 2017. A review of the TTA log for a similar period was also conducted. A sample
eUHR review of 30 cases of emergency mental health referrals for suicidal ideation/behavior
found that clinicians completed the required SREs in all of the cases.

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This reviewer also examined a sample of ten SREs from patients released from a MHCB
between July and October 2017. There was uneven consistency with discharging SREs
containing adequate safety plans in the reviewed sample. Most documents simply deferred the
development of safety plans to the yard clinicians. The following was an example (COR 1) of an
inadequate safety plan:
I/P is already on a 5-day f/u and to continue daily PC contact to address s/s and
monitor SI/HI.
1) Psychiatrist will prescribe and adjust medication as needed.
2) PC provide patient with Bible to read while in his cell.
3) PC will teach IP stress management and relaxation techniques to help decrease
stress and anxiety that seem to be increasing SI.
In addition, the first day of the patient’s Interdisciplinary Progress Note – 5-Day Follow-Up
(CDCR MH-7230-B) form stated the following under safety plan: “If sxs increase, IP to contact
staff/mental health staff immediately. Continue with current tx. plan.”
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 160 cases of inmates discharged from either
the MHCB unit or alternative housing that remained at CSP/Corcoran and were not transferred to
administrative segregation (where observation at 30-minute intervals was required) from midAugust through September 30, 2017. The review found that only 69 percent had Page One of the
“Discharge Custody Check Sheet” (MH-7497) forms completed correctly by mental health
clinicians, with approximately 78 percent of the custody checks recommended for between 48
and 72 hours. In addition, only 60 percent of the “custody check” forms (Page Two) were
completed correctly by correctional staff at 30-minute intervals. Problems found were related to
clinicians failing to complete and/or sign the forms, and time gaps for correctional officers
consistently conducting checks at 30-minute intervals.
Intervention: All reviewed housing units contained an emergency response bag that included a
micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (June through
August 2017) found that quorums were not achieved in any of the meetings. However, it was
noteworthy that there were between 13 and 16 participants at each monthly meeting. Meeting
minutes included a robust case presentation during July but were otherwise unremarkable. This
reviewer was also presented with a CAP based upon the previous suicide prevention assessment.
Dated October 5, 2016, the CAP indicated several items were noted to be “completed,” including
confidentiality during intake screening; allowable possessions, property, and privileges for
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MHCB patients; and safety planning for patients discharged from the MHCB. As indicated
above, this CAP was incorrect because such issues remained problematic.
Training: According to training records, 79 percent of custody and 98 percent of nursing staff
were currently certified in CPR. In addition, 96 percent of custody staff, 90 percent of medical
staff, and 88 percent of mental health staff completed annual suicide prevention block training
during 2016. Finally, as of September 2017, only 72 percent of mental health clinicians had
completed the SRE mentoring program, only 78 percent had received the seven-hour SRE
training, and only 74 percent had completed safety plan training. Similar low percentages for
SRE training were found during the previous assessment.
Recent Suicides: CSP/Corcoran experienced two inmate suicides during the review period. In
the first case (COR 2), the inmate was found hanging from the bunk by a sheet in his EOP
administrative segregation unit cell during the early morning of July 21, 2017. The inmate
entered the CDCR system on September 14, 2007 to serve a life sentence (with the possibility of
parole) for second-degree murder (of his best friend). He was transferred to CSP/Corcoran on
April 24, 2017. The inmate had 15 RVRs during his confinement, including ten for assault. The
last RVR occurred on June 4, 2017 for battery of an officer. The inmate was not known to be
gang-affiliated. His family support was said to be exaggerated since he had not had any family
contact since March 2016.
According to available documents, the inmate had a dysfunctional childhood and was raised by a
mother who experienced significant substance abuse. His father was incarcerated for most of his
young life. Records also indicated that the inmate was a victim of physical and emotional abuse
by his mother, who died in 2009. He had severe anger control deficits as a young child, as well
as significant involvement with the juvenile justice system for assaultive behavior. At age 13, he
was hospitalized for fighting with his brother and attempting to hold his entire family hostage.
He spent a significant amount of time in either foster care or group home environments. The
inmate also had a significant history of substance abuse, and the instant offense, which involved
the stabbing of his best friend, occurred while under the influence of drugs.
Other than being placed in two residential programs to treat his severe behavioral problems as a
juvenile, the inmate did not have any other mental health treatment in the community. Upon
entry into CDCR, he began to demonstrate delusional thinking shortly thereafter by refusing to
eat and claiming that his food had been poisoned by custody staff. He was initially placed at the
3CMS level of care with diagnoses of Psychotic Disorder NOS, Antisocial Personality Disorder,
and Traumatic Brain Injury (at age 7). His care was later elevated to EOP in August 2008, and
he was later placed in DSH on two occasions (2008 and 2010) for inpatient treatment. Such
delusional thinking triggered his refusal to eat, which correlated with a number of staff assaults.
As a result, a conservatorship was initiated in December 2009. He lost a significant amount of
weight between 2009 and early 2013 and had to be fed frequently for lengthy periods of time
with a feeding tube. In July 2013, a PC 2602 (involuntary medication order) for danger to others
was initiated, and the order was annually renewed by the court until his death. The inmate had
two other APP placements in November 2012 and May 2016, as well as MHCB placements in
April 2010, May 2012, August 2012, and April 2016, all for delusional behavior.

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The inmate had a significant history of suicidal behavior, including two suicide attempts by
overdosing while confined in a county juvenile detention facility. In 2005, he attempted suicide
by cutting himself in a county jail. In 2007, he slit his wrist after self-reporting “depression.” In
2012, he attempted to hang himself while housed in the SHU at CSP/Corcoran. He was later
placed in a MHCB. The inmate had multiple SREs completed during his confinement, the last
completed on May 3, 2017 and assessing his chronic risk for suicide as “high” and acute risk as
“low.”
In June 2017, following a staff assault, the inmate’s PC opined that his psychotic symptoms and
level of agitation appeared to be worsening. The inmate told the PC that he “heard voices every
waking moment….You guys are poisoning me with food and water…. I have green stuff coming
out of my ears, my urine and feces. I know you guys are trying to kill me. If I kill myself one
day, I get back at you guys for poisoning me.” The inmate’s IDTT decided to retain him at the
EOP level of care because “he was maintaining his activities of daily living and was medication
compliant.” However, the CDCR reviewer in this case found inconsistent clinical opinions about
his level of care, ranging from the PC advocating another DSH referral based upon “his current
level of functioning and delusional thoughts/beliefs,” to a psychiatric note dated July 18, 2017
and stating that the inmate “would be better served at the CCCMS level of care, because he was
not utilizing the therapeutic opportunities in EOP.” The psychiatrist was also concerned that the
inmate would be potentially assaultive to DSH staff. The inmate was seen by his PC on July 20,
2017, the day before his death. The progress note stated that he “denied having any mental
illness, ‘just an anger problem,’ and stated that he wanted to get away from EOP and the
psychiatrist, because he did not like being on medication. He went on to threaten both the PC
and the psychiatrist with violence.”
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and although he continued to suffer
from several medical issues related to his refusal to eat for long periods of time due to his
delusions, these issues were not viewed as proximate causes of his death.
The Suicide Report contained six recommendations for corrective action through a QIP:
1) Two days after the inmate transferred from COR to SVSP, a SRE dated
January 7, 2016 was performed. It appears the inmate’s suicide history was not
reviewed prior to this evaluation because his historical information was replaced
by information belonging to a different inmate, whose name is mentioned in the
“Estimate of Risk” section. The erroneous reporting in this SRE also contained
documentation of a suicide attempt by overdose in 2015 that was made by another
inmate. The two subsequent SREs (dated April 7, 2016 and April 14, 2016, at
9:45am) carried forth the same inaccurate historical information as contained in
the SRE dated January 7, 2016, and with other inmate information.
2) On July 5, 2017, the treatment team decided to retain the inmate in EOP, and
not refer him to DSH, despite his lack of attendance in any structured out-of-cell
activities, increased delusional symptoms, and increased anxiety/anger. Further,
it noted, “he had no current MHCB admissions” and “he appears to be relatively
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stable.” However, clinical progress notes indicated the inmate’s delusional
system appeared to continue to worsen. The level of care justification is
discrepant from the clinical progress documents within the file. On July 20, 2017,
the inmate was seen by his PC. Documentation indicated the inmate would be
retained at EOP level of care and work on reducing his paranoid
ideation/delusions and improve his sense of reality. She added that the inmate
would continue to “attend his 1:1 until being accepted to DSH.” However, it does
not appear that the IDTT had referred the inmate to DSH at that time. It is unclear
if there was any intent to refer the inmate to DSH. The clinical documentation is
inconsistent and the plan for the inmate’s clinical care and interventions are
unclear.
3) On July 18, 2017, a psychiatric note opined that the inmate would be better
served at the CCCMS level of care because he was not utilizing the therapeutic
opportunities in EOP. However, clinical documentation also indicated a
worsening of delusional symptoms that may have contributed to his willingness to
participate in mental health treatment. Lack of participation in treatment is not an
adequate justification for lowering inmates’ mental health level of care. It is
unclear whether the clinical team considered his current mental health
presentation and how it may have correlated with the inmate’s unwillingness to
attend EOP programming.
4) Activation of the Emergency Medical System (Calling 911) did not take place
until approximately six minutes into the emergency which caused a significant
delay in appropriate medical response. Although a request was made to activate
911 within one minute of discovery by the responding supervisor, the Watch
Office did not initiate the 911 call as identified in Operational Procedure No.
1083.
5) On July 21, 2017, RN documented administrating 25 liters of oxygen via BVM
(documentation error).
6) On July 21, 2017, Provider 2 (RN) gave a third dose of Narcan 0.8 mg IM in
the TTA without a provider order.
In the second case (COR 3), the inmate was found hanging from a ventilation grate by a sheet in
his STRH unit cell during the early afternoon of December 7, 2017. He had entered the CDCR
system on August 27, 2015 to serve an unidentified sentence length for second-degree robbery.
The inmate was 17-years-old at the time of the offense. He was transferred to CSP/Corcoran on
August 31, 2016. The inmate had seven RVRs during his CDCR confinement, the most recent
of which occurred on September 26, 2017 for possession of a dangerous weapon. He was known
to be gang-affiliated. The inmate was a victim of a gang-related assault on November 17, 2015.
(He would later be placed in SNY due to safety concerns shortly before his death.) Although his
mother had previously thrown him out of the family home, he enjoyed good family support with
her through telephone calls and letter correspondence, as well as occasional visits. The inmate
was unmarried and had one young daughter.
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The inmate was raised with three brothers and a sister by both parents but was self-described as
“the black sheep of the family” as he was the only one involved in gangs and the criminal justice
system (albeit limited). He had a long history of substance abuse, as well as a five-day
hospitalization at age 15 for “for depression, agitation, and anxiety.”
Upon entry into CDCR, the inmate self-reported having a history of depression, but denied any
current suicidal ideation or prior suicidal behavior. On September 14, 2015, he was placed in the
MHSDS at the 3CMS level of care for treatment of depression and substance abuse. His initial
diagnosis was Depressive Disorder NOS. Several weeks later in October 2015, he was assessed
by a psychiatrist and started on psychotropic medication “to treat symptoms of depression,
chronic anger, ruminating thoughts, and sad mood.” The inmate continued to be treated in the
3CMS program and remained stable enough that by March 2017 he requested to be removed
from the MHSDS. The inmate’s medication was eventually discontinued, and he remained
stable for the next several months.
During an IDTT meeting on October 4, 2017, clinicians noted that the inmate had no history of
suicidal thoughts or behavior, and although stable without medication, because he estimated his
depressive symptoms at “four out of 10…..and agitation related to incarceration issues at seven
out of 10,” he “could benefit from continued treatment for depression using CBT techniques to
help him learn to identify and modify cognitive distortions and use coping skills including
emotion regulation, distress tolerance skills.” The IDTT decided to retain the inmate in 3CMS
pending a review of his mental health needs by the treatment team in six months. However, a
few weeks later on October 23, 2017, a PT submitted an emergency mental health referral after
the inmate stated that “I’m going to hurt myself.” Although seen by a mental health clinician,
the required SRE was not completed. During a follow-up appointment with a clinician two days
later on October 25, the inmate denied any mental health distress or suicidal ideation, and the
clinician noted that he “was motivated for treatment, as reflected by the fact he had recently
completed at least four CBT workbooks.”
During an IDTT meeting on November 21, 2017, the inmate was found to be stable and
exhibiting no mental health symptoms and the team decided to discharge him from the MHSDS.
However, approximately 20 minutes following his IDTT meeting, the inmate reported to custody
staff that he needed SNY due to safety concerns. He was escorted to the STRH unit for further
assessment. The following day (November 22), the inmate reported suicidal ideation and was
seen by a clinician who concluded that “IP presented void of acute distress/crisis but is endorsing
DTS with high likelihood of staff manipulation….Intermittently uncooperative evidence by
being evasive with questions and potential for feigning symptoms for secondary gain to avoid
process from mainline to SNY requiring STRH temporary placement.” The inmate had admitted
to the clinician that he wanted to bypass the STRH and obtain SNY status as soon as possible, as
well as asking to return to the 3CMS program. The required SRE was completed and the inmate
was referred to an MHCB due to his “adamant” report of suicidal ideation. He remained in the
MHCB until December 3 when he was returned to the STRH unit. His diagnosis in the MHCB
was revised to be Adjustment Disorder with Depressed Mood. His final SRE assessed both his
chronic and acute risk for suicide as “low.” The CDCR reviewer in this case subsequently found
that the safety plan contained within the discharging SRE, as well as four days of
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Interdisciplinary Progress Note – 5-Day Follow-Up (CDCR MH-7230-B) forms, did not
adequately reflect safety planning to reduce SI.
On December 4, 2017, three days before his suicide, the inmate was interviewed by a captain and
stated, “he had heard rumors in the facility indicating he was considered to be in ‘bad standings’
with the Crips.”
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and there were no medical issues in
his case that were viewed as proximate causes of his death. Although a suicide note was not
found in his cell, the reviewer opined that the inmate “had frequently reported a connection
between safety concerns, symptoms of depression, and suicidal ideation. The inmate’s mood
appeared to be substantially impacted by realistic fear reactions to external events, which he
perceived to have a strong potential for impacting his safety. Additionally, the inmate indicated
he feared not being able to be with his mother before she died of breast cancer. Finally, fear of
potential future gang-related problems appears to be another plausible contributory factor.”
The Suicide Report contained nine recommendations for corrective action through a QIP:
1) On October 23, 2017, a primary clinician interviewed the inmate, but did not
perform a Suicide Risk Evaluation, although the psychiatric technician who made
the emergency referral noted the inmate having reported, “I’m going to hurt
myself.” In the corresponding progress note, the clinician failed to adequately
document the reason for this referral, sufficiently explore his statement of
intended self-harm, or develop a safety plan to address intended self-harm.
2) The IDTT documented on the Mental Health Master Treatment Plan completed
on November 21, 2017 recommended removal from MHSDS. However, the
transfer/discharge planning section was empty, and the case formulation section
and clinical summary were inadequate. During the performance of a “Danger to
Self” Patient Level Outcome interview at the IDTT meeting, the inmate answered
“somewhat often” to the question of how frequently he thought about suicide
lately. In spite of this assessment, the clinician reported the inmate to be free of
symptoms. The clinical rationale for discharge from MHSDS appeared to be
based on symptom remission while medication-free for six months. However, an
Individual Plan of Care (IPOC) for depressed mood was activated at this IDTT,
which is inconsistent with his reports of remission and discharge from the
MHSDS.
3) On November 22, 2017, a clinician interviewed the inmate in response to an
emergency referral by ASU staff, because the inmate reported suicidal ideation.
The clinician did not document the reason for conducting the interview in a nonconfidential setting, where she posed a number of specific questions related to the
inmate’s reported safety concerns.

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4) A progress note and SRASHE dated November 22, 2017 primarily focused on
a diagnostic impression of manipulation and malingering. The clinician did not
document the nexus between the inmate’s safety concerns, depression, and his
suicidal ideation, and minimized the present risk factors by focusing primarily on
manipulation and malingering. Additionally, the assessing clinician omitted the
Columbia Suicide Severity Rating Scale (C-SSRS), which led to the omission of
important historical information related to the inmate’s suicidal ideation.
5) Records show that the assessing mental health clinician for the November 22,
2017 evaluation did not complete the mandatory trainings: “Safety Planning
Webinar” and “Differential Diagnosis of Complex Cases in Corrections.” The
clinician stated she was not aware of and had not been offered these trainings.
6) Records show that the mental health clinician who conducted the November
22, 2017 evaluation had not attended the C-SSRS training. However, the
Statewide Mental Health Program (SMHP) had not yet placed the C-SSRS
training on the list of mandatory trainings.
7) The documentation from the inmate’s MHCB admission from November 22,
2017 through December 3, 2017 had a number of deficiencies.
8) The inmate was discharged from the MHCB on December 3, 2017. Four 5Day follow-up evaluations were completed prior to his death (the inmate died on
day five). On the 5-Day follow-up evaluations completed by a mental health
clinician, the safety plans did not contain individualized treatment interventions
targeting his triggers (i.e., safety concerns).
9) Activation of EMS (911): approximate 10-minute delay for EMS activation.
12)

California Substance Abuse Treatment Facility (CSATF)

Inspection: October 12-13, 2017 (previous suicide prevention audit on June 23-24, 2016).
CSATF housed approximately 5,814 inmates at the time of the on-site assessment.
Screening/Assessment: This reviewer observed a few new admissions during the intake
screening process in the R&R unit on October 12, 2017. The nurse was observed to be asking all
of the questions and correctly entering information into the EHRS. The door to the nurse’s
office remained closed, with officers stationed outside, thus ensuring both privacy and
confidentiality. Of note, based upon this reviewer’s previous recommendation, the intake
screening process had been relocated to a former examination room (Room 103) that contained a
TTM.
Daily PT rounds in the STRH unit were observed on October 13. The rounds were
unremarkable, and the PT was observed to be correctly completing the Psych Tech Daily Rounds
Forms and entering the information into the EHRS.

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Housing: CSATF had 20 MHCBs. A previously identified hazard (i.e., square-shaped stainlesssteel sinks protruding from the wall) had been corrected with installation of stainless-steel
triangle extensions. The rooms were now suicide-resistant and did not contain any obvious
protrusions which could be used in a hanging suicide attempt.
The facility had one administrative segregation unit (STRH), with GP inmates requiring
administrative segregation transferred to CSP/Corcoran. The STRH unit contained nine new
intake cells (100-108) that had been previously retrofitted to be suicide-resistant. Upon
inspection, all of the new intake cells were full on October 13. However, the facility received
eight new inmates the previous evening (October 12), resulting in several being placed in unsafe,
non-intake cells. A custody supervisor informed this reviewer that the STRH unit exceeded its
new intake cell capacity approximately every one to two weeks, and the supervisor had
recommended that an additional three cells be retrofitted for new intake inmates. To date, the
recommendation had not resulted in a work order.
Finally, alternative housing to temporarily house inmates identified as suicidal and awaiting
MHCB placement was extensively used on a daily basis. Two holding cells in the CTC and
designated cells in E-1 unit, formally administrative segregation, were primarily utilized for
alternative housing. All inmates had beds, with those housed in the CTC holding cells provided
stack-a-bunks and required to be observed on a 1:1 basis. From July 1 through October 9, 2017,
there were 357 inmates housed in alternative housing, with the majority (53 percent) released
within 24 hours. In addition, 34 percent of inmates were housed in alternative housing between
24 and 48 hours. The overall average length of stay in alternative housing for all 357 inmates
was 24 hours. (Of note, a previous very problematic practice of handcuffing inmates to gurneys
in two TTA examination rooms had been discontinued following this reviewer’s preceding
assessment.)
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCB unit. In addition, patients not on suicide observation status were now required to be
observed at 15-minute intervals by nursing staff, modifying a previous practice that allowed 60minute rounds. This reviewer subsequently verified the accuracy of observation rounds by
reviewing the EHRS charts of four patients (CSATF 1, CSATF 2, CSATF 3, and CSATF 4) on
Suicide Precaution status in the CTC for an eight-hour period from 12:00 a.m. through 7:59 a.m.
on October 12, 2017. The chart review found a few observation checks that were in excess of
the required 15-minute intervals for the four patients. In fact, there were no violations for cases
CSATF 1 and CSATF 4, but six violations for CSATF 3 and nine violations for CSATF 2. Of
note, the CNE informed this reviewer that nursing leadership had previously determined that
there were not enough certified nursing assistant (CNA) staff assigned to the CTC in order to
consistently complete observation of MHCB patients at 15-minute intervals. As a result, a
determination was made that a staff-to-patient ratio of to 1:7 was required, and additional CNA
staff were subsequently assigned to the MHCB unit.
A previous problem with patients being clothed in safety smocks or “partial-issue” clothing
despite the fact they were not on suicide observation status had been corrected, as all patients
were observed to be clothed consistent with their level of risk or lack thereof. In fact, this
reviewer observed many MHCB patients in “full-issue” uniforms. The MHCB unit still did not
have a RT, a problem found during the preceding assessment. As such, there was limited use of
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both the program office and telephone access, but most patients were offered yard access that
was provided by custody personnel upon their availability.
This reviewer observed five IDTT meetings on October 12, 2017. The treatment team was well
represented by mental health, medical, and custody staff, and there were robust discussions
observed during the meetings, with each averaging approximately 30 minutes in duration.
However, although there was significant discussion (primarily between the PCs, CC I and
patients) about an assortment of issues, ranging from the MHCB process, parole planning, GED
classes and treatment groups, and milestone credits, there was little, if any, discussion regarding
safety planning to reduce SI, particularly for the two patients who were being discharged from
the MHCB that day. For example, in one of those cases (CSATF 1), the patient had been
admitted into the MHCB unit nine days earlier for depressed mood, paranoia, bizarre delusions,
and suicidal ideation. The patient was at EOP level of care and, although viewed as an
unreliable historian regarding his history of suicidal behavior, he remained suicidal for most of
his MHCB placement. During the IDTT meeting on October 12, the team decided to discharge
the patient without any discussion of safety planning nor even any inquiry regarding current
suicidal ideation. A subsequent review of the patient’s discharging SRASHE included the
following safety plan that was not discussed during the IDTT:
1) Psychiatrist will continue with medication evaluation and monitoring (100%
medication compliance); 2) IP to learn three emotional regulation techniques such
as deep breathing, thought stopping negative thoughts and replace with positive
self-talk, and/or distractions like reading, journaling, writing letters, exercise,
dayroom leisure activities over the next 30 days to improve mood to a 4/10 or
better, decrease impulsivity as a way to prevent SI and MHCB admits; 3) PC to
remind and encourage IP to engage in more solution-focused behavior such as
identifying appropriate resources to problems (custody, medical, MH) and
participating in EOP psychoeducational groups.
Finally, a review of Guard One data for a recent 24-hour period found 100-percent compliance
with required checks that did not exceed 35-minute intervals.
Management/Treatment Planning: This reviewer requested and subsequently reviewed a
listing of emergency mental health referrals from the MHTS for the period of April 1 through
September 30, 2017. The TTA log for the same time period was also reviewed. This reviewer’s
sample EHRS review of 40 emergency mental health referrals for suicidal ideation/behavior
found that mental health clinicians subsequently completed the required SRASHEs in 95 percent
(38 of 40) of the cases. This was an improvement from the previous assessment when only an
89-percent compliance rate was found.
This reviewer examined a sample of ten SRASHEs from patients released from the MHCB unit
from August through early October 2017. Although a few safety plans contained within the
discharging SRASHEs were adequate, most did not include specific strategies to reduce future
SI. For example, in one case (CSATF 5), the patient had been admitted into the MHCB unit 11
days earlier on September 29, 2017. He had at least three previous suicide attempts, as well as

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multiple prior reports of suicidal ideation resulting in five MHCB admissions. The entirety of
the safety plan section of the discharging SRASHE dated October 9, 2017 was the following:
IP will contact clinician on yard to assist with problem-solving and verbalize
feelings of distress in order to manage stressors effectively and avoid future SI.
In addition, the first day of the patient’s Interdisciplinary Progress Note – 5-Day Follow-Up
(CDCR MH-7230-B) form dated October 10, 2017 stated the following under safety plan: “1)
increase drinking fluids during the day time, but not after 7pm, 2) Ask to talk to PC if SI
symptoms increase, 3) Reading and watching some TV.”
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 454 cases of patients discharged from either
the MHCB unit or alternative housing that remained at CSATF and were not transferred to
administrative segregation (where observation at 30-minute intervals was required) during April
through September 2017. The review found that 87 percent had Page One of the “Discharge
Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental health clinicians,
with the majority of the custody checks recommended for 48 hours by clinicians. In addition, 98
percent of the “custody check” forms (Page Two) were completed correctly by correctional staff
at 30-minute intervals. The few problems found included clinicians discontinuing custody
checks in less than the required 24 hours, as well as some gaps in observation by custody
personnel. Of note, all of the Discharge Custody Check Sheet (CDCR MH-7497) packets were
found to be extremely well-organized.
Intervention: All housing units toured by this reviewer contained an emergency response bag
that included a micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (July through
September 2017) found that quorums were only achieved during one month (September).
Meeting minutes were otherwise unremarkable.
Training: According to training records, 97 percent of custody staff and 100 percent of nursing
staff were currently certified in CPR. In addition, 97 percent of custody staff, 84 percent of
medical staff, and 94 percent of mental health staff received annual suicide prevention block
training during 2016. Finally, as of September 2017, 81 percent of mental health clinicians had
completed the SRE mentoring program, 92 percent had received the seven-hour SRE training,
and 76 percent had completed safety plan training.
Recent Suicides: CSATF did not experience any inmate suicides during the review period.
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13)

High Desert State Prison (HDSP)

Inspection: November 2-3, 2017 (previous suicide prevention audit was on November 8-9,
2016). HDSP housed approximately 3,502 inmates at the time of the on-site assessment.
Screening/Assessment: The intake screening process within the R&R unit was not observed
because there were not any new inmates admitted into the facility during the two-day
assessment. Daily PT rounds in the STRH unit were observed on November 3. The rounds were
unremarkable, and the PT was observed to be correctly completing the Psych Tech Daily Rounds
Forms and entering the information into the EHRS.
Housing: HDSP had ten MHCBs and all rooms were suicide-resistant and did not contain any
obvious protrusions which could be used in a hanging suicide attempt. The STRH unit contained
six retrofitted new intake cells (100-105) and had been relocated to Z-Unit. During inspection of
the unit, this reviewer observed several empty new intake cells, however, a new intake inmate
who had arrived on November 1 was housed in an unsafe, non-new intake cell. During the
previous assessment, this reviewer had been informed that the facility received approval for
renovation of approximately 17 additional new intake cells. Because the STRH unit had since
been relocated to Z-Unit, it was unclear if, or when, any additional new intake cells would be
available.
Finally, alternative housing to temporarily house inmates identified as suicidal and awaiting
MHCB placement was infrequently used at the facility. From July 1 through October 30, 2017,
only 58 inmates were housed in alternative housing, and all released within 24 hours. An
observation room (Room 11) in the CTC was primarily utilized for alternative housing and
contained an MHCB bed; other designated CTC medical rooms or holding cells could also be
utilized. All inmates were provided stack-a-bunks in the CTC medical rooms/holding cells and
observed on a continuous 1:1 basis. The exact length of stay in alternative housing for these 58
inmates was unavailable but estimated to be 24 hours.
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCB unit. In addition, patients not on suicide observation status were observed at 30-minute
intervals by nursing staff. This reviewer subsequently verified the accuracy of observation
rounds by reviewing the EHRS charts of four patients on Suicide Precaution status in the MHCB
unit during nine-hour periods from 12:00 a.m. through 8:59 a.m. on several sample days (i.e.,
November 2 for HDSP 1 and HDSP 2, August 8 for HDSP 3, and October 9 for HDSP 4). The
chart review found numerous observation checks (between two and ten per patient) that were in
excess of required 15-minute intervals, with the longest gap between checks being 35 minutes in
one case (HDSP 3). The following case (HDSP 3) exemplified the extent of the problem: There
were five violations of 35-, 20-, 16-, 18-, and 23-minute gaps between the required 15-minute
intervals. Violations in the four cases were by multiple nursing staff during multiple days.
A previous problem with patients being clothed in both “partial-issue” and safety smocks had
been corrected, and there were no problems observed regarding the issue of privileges within the
MHCB unit. There was a full-time RT assigned to the unit and patients were receiving out-ofroom activities, including yard. In fact, this reviewer observed two IDTT meetings in the MHCB
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unit on November 2 and the PC had a uniquely good practice of going through both patients’
CDCR 114-A Form and carefully explaining the privileges that they would be eligible for during
their MHCB placement based upon clinical judgment. The treatment team was well represented
by mental health, medical, and custody staff. The psychiatrist attended via tele-psychiatry.
There was not much discussion in either case regarding safety planning, despite the fact that one
patient (HDSP 1) was discharged from the MHCB unit during the IDTT meeting.
Finally, a review of Guard One data for a recent 24-hour period in the STRH unit found 100percent compliance with the required checks that did not exceed 35-minute intervals.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS from April through October 2017.
A sample EHRS review of 60 emergency mental health referrals for suicidal ideation/behavior
revealed that clinicians completed the required SRASHEs in 90 percent (54 of 60) of the cases.
In addition, this reviewer examined a sample of ten SRASHEs from patients released from a
MHCB from August through early November 2017. Although all of the SRASHEs mentioned
safety planning to reduce SI, few offered specific strategies to reduce risk. For example, one
case (HDSP 5) was representative of the problem. The clinician wrote the following in the
safety plan section of the discharging SRASHE:
His prior safety plan/treatment plan focused on stabilizing his mood, developing
goals for the future, and developing alternative strategies for relief besides cutting
(self-harm). The Pt currently states a safety plan is adequate for keeping him safe.
The above narrative failed to identify the specific “goals” and “strategies” contained within
either the current or previous safety plan that was effective for the patient.
In contrast, although not discussed during the observed IDTT meeting, the safety plan for the
patient (HDSP 1) discharged from the MHCB on November 2, 2017 was specific (albeit
lengthy):
Continue treatment for recent depression related to family issues. Work with
patient in individual and group tx utilizing CBT to reduce depressive symptoms
and increase coping skills regarding environmental stressors. He will continue to
engage in positive coping, including regular exercise, phone calls with his family,
religious practices, and reading. DSH discharge summary from 2013, pt reported
that he copes by listening to music and it was recommended that the pt should not
have KOP medication in significant quantities.
A common stressor that has been documented as the source of the patient’s
suicidal ideation is being far away from his family and grief and loss. When the
patient’s father passes away the pt will likely struggle to maintain his positive
coping skills and will require significant support from the mental health team. It
may be helpful to start processing grief and loss to prepare the patient for future
situations involving grief and loss.
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Due to the patient’s recent relocation to HDSP and recent MHCB discharge pt
should be met with frequently over the next couple of weeks to ensure a smooth
transition to EOP LOC. Pt should check in about continued phone calls with his
family, and issues related to him receiving his property (specifically his radio, as
this is a reported coping skill), and provide examples of his participation in
positive coping skills, such as exercise, religious practices, and reading.
Additionally, if pt begins to sell his property items this could indicate an increase
in his suicidal ideation. Additionally, the pt should be considered for being clear
for double cell due to MH symptoms.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 46 cases of patients discharged from a
MHCB or alternative housing placement that remained at HDSP and were not transferred to the
STRH unit (where observation at 30-minute intervals was required) from March through October
2017. The review found that only 80 percent had Page One of the “Discharge Custody Check
Sheet” (CDCR MH-7497) forms completed correctly by mental health clinicians, with most of
the custody checks recommended for only 24 hours by clinicians. In addition, only 67 percent of
the “custody check” forms (Page Two) were completed correctly by correctional staff at 30minute intervals. Most of the deficiencies found included clinicians discontinuing custody
checks in less than the required 24 hours, as well as some gaps in observation by custody
personnel.
Intervention: All housing units toured by this reviewer contained an emergency response bag
that included a micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (July through
September 2017) found that quorums were not achieved in any of the meetings. The meeting
minutes were otherwise unremarkable.
Training: According to training records, 99 percent of custody staff and 100 percent of nursing
staff were currently certified in CPR. In addition, 100 percent of custody staff, 71 percent of
medical staff, and 85 percent of mental health staff received annual suicide prevention block
training during 2016. A similar low compliance rate for annual suicide prevention training by
medical and mental health staff was found during all previous assessments. Finally, as of
October 2017, 62 percent of mental health clinicians had completed the SRE mentoring program,
100 percent had received the seven-hour SRE training, and 100 percent had completed safety
plan training.

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Recent Suicides: HDSP did not experience any inmate suicides during the review period.
14)

California State Prison - Los Angeles County (CSP/LAC)

Inspection: November 13-15, 2017 (previous suicide prevention audit was on April 28-29,
2016). CSP/LAC housed approximately 3,410 inmates at the time of the on-site assessment.
Screening/Assessment: This reviewer observed a few new admissions during the intake
screening process in the R&R unit on November 14, 2017. The nurse was observed to be asking
all of the questions and correctly entering information into the EHRS. The door to the nurse’s
office remained closed, with officers stationed outside, thus ensuring both privacy and
confidentiality.
Daily PT rounds in the STRH unit and EOP administrative segregation unit (D-5) were observed
on November 14. The rounds were unremarkable, and the PTs were observed to be correctly
completing the Psych Tech Daily Rounds Forms and entering the information into the EHRS.
Housing: CSP/LAC had a 16-bed CTC, with 12 rooms designated as MHCBs. All MHCB
rooms were found to be suicide-resistant and did not contain any obvious protrusions which
could be used in a suicide attempt by hanging.
The STRH unit had 12 retrofitted cells for inmates on new intake status, with five of the cells
added since the previous assessment. The EOP administrative segregation unit (D-5) had eight
retrofitted new intake cells, with two of the cells added since the preceding assessment. During
inspection of both units, this reviewer observed that all new intake inmates were in new intake
cells. Of note, however, a new intake inmate (LAC 1) committed suicide in an unsafe non-intake
cell in the EOP administrative segregation unit on August 4, 2017.
Finally, alternative housing cells to temporarily house inmates awaiting MHCB placement were
found in a variety of designated locations, including TTA wet holding cells within the CTC, the
EOP administrative segregation unit (D-5), and the overflow administrative segregation unit (D4). This reviewer was informed that TTA dry cells were no longer utilized for alternative
housing. All inmates were furnished beds, with stack-a-bunks utilized in the TTA wet holding
cells and required to be observed on a 1:1 basis. From August 1 through November 8, 2017,
there were 310 inmates placed in alternative housing, with the majority (63 percent) released
within 24 hours. In addition, approximately 14 percent of inmates were in alternative housing
over 48 hours. The overall length of stay in alternative housing for these 310 inmates was 26
hours.
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCB. In addition, patients not on suicide observation status were not being observed at any
interval by nursing staff. As discussed below, such a practice was identified in the previous
assessment and continued to be contrary to CDCR policy.
This reviewer subsequently verified the accuracy of observation rounds by reviewing the EHRS
charts of four patients on Suicide Precaution status in the MHCB unit during nine-hour periods
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from 12:00 a.m. through 8:59 a.m. on several sample days (i.e., November 9 for LAC 2 and LAC
3, November 12 for LAC 4, and November 13 for LAC 5). The chart review found numerous
observation checks (i.e., between eight and nine per patient) that were in excess of required 15minute intervals for LAC 2 and LAC 3, with the longest gap between checks being 28 minutes.
The violations in the other two cases were alarming. For example, in one case (LAC 4), there
were multiple time gaps including two and three hours (from 12:12 a.m. to 2:05 a.m. and then
from 2:07 a.m. until 5:38 a.m. on November 12. In the other case (LAC 5), there were multiple
time gaps that included a five-hour period (12:19 a.m. until 5:28 a.m.) on November 13. Later
that morning, the patient was observed with a piece of cloth tied around his neck at
approximately 12:00 p.m. He had last been observed 24 minutes earlier at 11:36 a.m.
A previous problem with patients being clothed in both “partial-issue” clothing and safety
smocks, as well as clinicians under the incorrect assumption that patients needed to be
discontinued from a suicide observation level in order to be “eligible” for activities such as yard,
telephone calls, and visits, had been corrected. Patients were observed to be appropriately
clothed consistent with their level of suicide risk or lack thereof. In addition, an RT had been
assigned to the MHCB unit the week prior to this reviewer’s assessment for up to 12 hours per
week and out-of-room activities, including yard, were beginning to be made available.
This reviewer observed nine IDTT meetings for MHCB patients on November 13 and 14.
Although there was good representation from custody, medical, and mental health personnel,
several problems were observed. First, of the 12 patients housed in the MHCB unit on
November 14, only three were on either Suicide Watch or Suicide Precaution status. Although
the LOP required that patients not on suicide observation status be observed at 30-minute
intervals, the remaining nine patients were not being observed at all by nursing staff. IDTT
members appeared unaware of this policy when it was reiterated by this reviewer, even though
the issue had been identified in the previous assessment. Second, in at least one case (LAC 6),
the patient was admitted to the MHCB on November 9, 2017 for suicidal ideation. Despite
continuing to voice SI throughout his placement, he was discontinued from Suicide Precaution
status two days later on November 11. During his IDTT meeting on November 13, the patient
continued to express suicidal ideation, as well as experiencing auditory hallucinations “all the
time telling him to kill himself,” but still was not placed on Suicide Precaution status. Third, of
the nine IDTT meetings observed, there was some discussion of safety planning in four cases,
but not in the two cases in which both patients were released from the MHCB on November 14.
Finally, a review of Guard One data for a recent 24-hour period found 96-percent compliance
with required checks not exceeding 35 minutes in the STRH unit and 97-percent compliance in
administrative segregation EOP. Of note, however, CSP/LAC experienced a suicide in May
2017 in which the suicidal inmate (LAC 7) was placed in a STRH unit holding cell pending a
mental health evaluation and left unobserved for over 60 minutes. On August 4, 2017, another
inmate (LAC 1) committed suicide and his body was found in a state of rigor mortis in the EOP
administrative segregation unit, an indication that Guard One checks were not completed as
required. As detailed in the previous assessment, there were questionable Guard One practices
involving an inmate who committed suicide in the STRH unit in April 2016.

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In sum, the multiple violations of required observation of MHCB patients on suicide
precaution status, including cases involving gaps of two, three, and five-hour periods of time
was extremely problematic at CSP/LAC and continued following this reviewer’s November
2017 assessment. In addition, there were 27 observation checks that were in excess of
required 15-minute intervals during the 14 hours leading up to the suicide of a MHCB patient
(LAC 8) on December 5, 2017. Finally, high compliance rates for Guard One in the
administrative segregation units were offset by continuing questionable Guard One practices
related to two suicides that occurred in May and August 2017.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS from May through November 10,
2017. In addition, the TTA log for the same time period was also reviewed. This reviewer’s
sample eUHR and EHRS review of 54 emergency referrals for suicidal ideation/behavior
revealed that clinical staff completed the required SRE/SRASHEs in only 85 percent (46 of 54)
of the cases.
This reviewer examined a sample of ten SRE/SRASHEs from patients released from a MHCB
between September and November 2017. Although there was some progress noted in the quality
of safety plans from previous assessments, most of the reviewed plans simply recommended that
the patient identify coping skills and strategies to reduce SI with the receiving clinician. For
example, in one case (LAC 9) in which the patient was in the MHCB for ten days, and had a
history of at least three suicide attempts and multiple MHCB placements, the safety plan
contained within the discharging SRASHE stated the following:
1) IP to return EOP LOC w/5-day step down.
2) IP will have no self-reported and/or collateral self-reported incidents of SIB
(cutting or hanging) over the next 90 days.
3) IP will identify 3 things that prevent him from harming himself and learn to
focus on these things when he has thoughts of self-harm over the next 90 days. IP
agreed to verbal safety plan and will notify custody if he is unable to control
thoughts of self-harm or has intent or desire to harm himself.
4) IP will learn 2 strategies (e.g., journaling, letter writing) to start to process the
death of his uncle and utilize the strategies at least once a day over the next 90
days.
In another case (LAC 10), a patient who had been in the MHCB for five days, had a “high”
chronic risk for suicide, and had previously been on the facility’s High-Risk List, had the
following safety plan developed by another clinician:
CBT/DBT model recommended to identify 1-2 effective coping skills to manage
distress tolerance and reduce MHCB admits/crisis evaluations during PC contacts
in the next 90 days. IP to learn 3 new calming strategies to assist in managing
anger response during 1:1 PC contacts in the next 90 days. Identify at least 3
thoughts that trigger irritability within the next 90 days. Reframe at least 3
negative thoughts that enhance agitation into a more neutral thought during each
individual session over the next 90 days. He has several protective factors
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motivating his self-preservation such as getting his non-mental health needs met,
family support including children in past suicide attempts that were situational
specific, and more distant in time.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 319 cases of patients discharged from a
MHCB or alternative housing placement that remained at CSP/LAC and were not transferred to
the administrative segregation units (where observation at 30-minute intervals was required)
from May through October 2017. The review found that 91 percent had Page One of the
“Discharge Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental
health clinicians, with the vast majority (86 percent) of the custody checks recommended for the
full 72 hours by clinicians. In addition, only 57 percent of the “custody check” forms (Page
Two) were completed correctly by correctional staff at 30-minute intervals. Most of the
deficiencies found were gaps in observation by custody personnel.
Intervention: Housing units toured by this reviewer all contained an emergency response bag
that included a micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (August through
October 2017) found that quorums were not achieved in any of the meetings. The meeting
minutes were otherwise unremarkable.
Training: According to training records, 82 percent of custody staff and 100 percent of nursing
staff were currently certified in CPR. In addition, 93 percent of custody, 59 percent of medical,
and 55 percent of mental health staff received annual suicide prevention block training during
2016. Similar low percentages of medical and mental health staff completing annual suicide
prevention block training was found in the previous assessment. Finally, as of October 2017,
only 50 percent of mental health clinicians had completed the SRE mentoring program, 99
percent had received the seven-hour SRE training, and 66 percent had completed safety plan
training.
Recent Suicides: CSP/LAC experienced four inmate suicides during the reporting period. In
the first case (LAC 11), the inmate was found hanging from a ventilation grate by a bed sheet in
his GP cell during the afternoon of March 26, 2017. He had entered the CDCR system on March
3, 2016 to serve a sentence of unidentified length for resisting/deterring an officer with threat of
violence. He was transferred to CSP/LAC on March 16, 2017. The inmate had two RVRs
during his confinement, one for fighting on February 28, 2017, and the second for sexual
disorderly conduct on March 15, 2017. He was not known to be gang-affiliated. The inmate had

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family support from both parents through letter correspondence, as well as regular visits from his
mother. He was unmarried with an 18-month-old son.
According to available records, the inmate had a very dysfunctional childhood. His parents
divorced when he was 6 years old, and as a result of child abuse, was removed from the home at
age 13. He subsequently lived in foster care and group homes. The inmate had a history of
substance abuse beginning in early childhood. He was also involved in both the juvenile and
criminal justice systems. He served his first CDCR term from 2006 through 2013.
As a teenager, the inmate was diagnosed and treated for ADHD, Bipolar Disorder, and
depression. He was reportedly hospitalized once for a suicide attempt by overdose in 2000.
During his first CDCR term, the inmate was admitted to DSH in 2011 for depression, anxiety,
hopelessness, and suicidal ideation, with a plan to stab himself in the neck. Prior to his second
term, the inmate self-reported a suicide attempt in the county jail in 2015. Upon entry into
CDCR for the second term, he was placed in the MHSDS at the 3CMS level of care with a
diagnosis of Mood Disorder NOS and Antisocial Personality Disorder. The inmate also reported
visual hallucinations. He admitted to having used illegal drugs in the past as well as in CDCR,
and although not found to be psychotic, the connection between his drug use and past psychotic
symptoms was implied in his mental health records. He was admitted into the MHCB on two
occasions in December 2016 and February 2017. Both admissions were for suicidal ideation
based upon the loss of his young son to adoption, recent death of his grandmother, anxiety
related to his upcoming release, and for receiving an RVR for fighting. His diagnoses of Mood
Disorder and Antisocial Personality Disorder remained unchanged.
Upon arrival to CSP/LAC in March 2017, the inmate was evaluated for admission into the
MHCB on three occasions (March 17, March 21, and March 22), but never admitted. All three
emergency mental health referrals were based on suicidal ideation, “fear that he would never
make it out of prison alive,” and stress about his son’s adoption and recent death of his
grandmother. The inmate had two SREs completed on March 22, 2017. According to the
CDCR reviewer in this case:
Documentation in the first assessment quoted the inmate as stating, ‘I did
something that put me at risk,’ ‘they are going to kill me,’ ‘I am a piece of shit, I
am not safe,’ ‘If I go back to my cell I am going to jump off the tier or hang
myself,’ and ‘I am going to kill myself because I’m going to die anyway.’ A
second SRE was performed and 1310 hrs. to determine the inmate’s need for a
higher level of care. Although the inmate was observed to have cut himself while
waiting for assessment, an LPT had informed the crisis clinician that the inmate’s
wounds had been medically-cleared, and that they were ‘superficial.’ No
documentation regarding a medical clearance by a physician can be found. The
crisis clinician documented that the inmate had calmed down. The crisis clinician
noted that the inmate’s reason for cutting himself previously was aimed at getting
a cell move, and that his move was in process….The crisis clinician noted the
inmate denied all suicidality (intent, plan, and means).

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According to the CDCR reviewer in this case, although the inmate did not have any medical
issues that were viewed as contributory to his death, and he did not leave a suicide note, “Over
the past month or so, the inmate had persistently expressed concerns for safety…. Engaged in
self-harm behavior, made statements regarding his intent to end his life, and was observed to be
acting erratically…. He did not leave an explanation of the reasoning to end his life. However,
the fear of retaliation for his actions during an altercation, loss of his child through adoption, and
his fear of failure upon his July 2017 release appeared to be plausible contributory factors.”
The Suicide Report contained 11 recommendations for corrective action through a QIP:
1) Custody staff responding to this incident failed to respond with the appropriate
cut-down kit, but rather the cut-down tool alone, while another officer responded
with the Ambu bag.
2) The inmate was secured in the shower versus a holding cell in boxer shorts for
a total of 5 hours and 25 minutes while awaiting a mental health assessment on
March 22, 2017. LAC #511 identifies use of showers as holding cells is not
recommended separate except for incidents where no other option is available or
practical. In addition, if clothing is confiscated from the inmate, new clothing
shall be issued, such as the jumpsuit.
3) An initial SRE performed at DVI-RC on March 8, 2016 marked ‘no’ for all
chronic risk factors, except ‘yes’ for “male.” All acute factors marked ‘no,’
except for ‘recent cell change’ and ‘single cell status.’ There was no reference to
a review of the inmate’s first clinical documentation and suicide assessments,
which would have provided consistent reference to his chronic risk factors,
including the suicide attempt. A second mental health evaluation on March 22,
2016 referenced his first term clinical documentation and placed the inmate in
CCCMS due to his clinical treatment history. It is unclear if there were barriers
with the chart, making the prior clinical documentation unavailable to the
assessing clinician on March 8, 2016; however, the documents were available for
reference on March 22, 2016 and the inclusion of the information prompted a
CCCMS level of care recommendation.
4) Two SREs were completed on March 22, 2017. The PC completed the SRE at
1018 hours and noted 9 acute and 7 chronic factors; the suicide risk was estimated
as moderate chronic and high acute. The second SRE was conducted three hours
later, and reports indicated the inmate had cut his arm in the shower while
awaiting the assessment. This SRE identified 6 chronic risk factors and no acute
risk factors; the risk was estimated as moderate chronic and low acute risk for
suicide. The top of this SRE had a written statement – ‘treat as original as of
3/27/17.’ The inmate was not referred for an MHCB admission and the safety
plan indicated: ‘I/P was educated to always contact any staff when in crisis and
also safety planning reviewed during contact. Provided psychoeducation on
working with PC on appropriate ways to advocate for needs w/out resorting to
maladaptive bxs.’ Per consultation with facility supervisors, the first SRE was
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reportedly not available in the system at the time of the assessment. The progress
note and SRE for the MHCB evaluation does not provide a clinical rationale for
not recommending additional precautions or resources, or for not admitting the
inmate to the MHCB. It is unclear whether the PC was consulted for this MHCB
evaluation; however, the collaboration would have been useful given the
discrepant presentations by the inmate.
5-11) Seven nursing care concerns were identified. The concerns are listed above
and considered contributory to the death. (Three of these nursing concerns
occurred at DVI, one occurred at CHCF, two occurred at CSP/Sac, and one
occurred at CSP/LAC. All related to documentation and medication errors.)
In the second case (LAC 7), the inmate was found hanging from an unidentified fixture in a
STRH holding cell during the early evening of May 18, 2017. He had entered the CDCR system
on May 11, 2004 to serve a sentence of 40-years-to-life for second-degree murder. The inmate
was transferred to CSP/LAC on March 15, 2012. He had 14 RVRs, most of which involved
alcohol possession and threatening staff and other inmates. The most recent RVR occurred on
May 6, 2017 and involved throwing feces and trash out of his cell, resulting in his STRH unit
placement. The inmate was not known to be gang-affiliated. He had some family support,
including irregular visits from his mother.
According to limited available records, the inmate had a dysfunctional childhood and was the
oldest of seven children. His childhood included a history of physical abuse by family members
and sexual abuse by a stranger. Both his father and a sister had involvement in the criminal
justice system. There was also a significant family history of mental health problems. The
inmate had a limited juvenile and adult criminal history. He had no known mental health history
in the community. There were inconsistent reports about his marital status.
During the first ten years of his CDCR confinement, the inmate was in the MHSDS for brief
periods of time including 2005 and 2009-2010. During both of these periods, episodes involving
affective and psychotic symptoms were reported. He was initially diagnosed with Major
Depressive Disorder, Severe with Psychotic Features in 2005, and was discharged from 3CMS in
May 2010 with a diagnosis of Antisocial Personality Disorder. In April 2014, the inmate was
referred to mental health after smearing feces on his body and around his cell. He re-entered the
MHSDS at 3CMS level of care with a diagnosis of Psychotic Disorder NOS and subsequently
had three MHCB placements that year for grave disability and suicidal ideation. He was often
suspected of “malingering,” and according to the CDCR reviewer in this case, “Secondary gain
was suspected, with a motivation of attaining EOP placement rather than CCCMS level of care.
He was seen as a low acute and low chronic risk for suicide.”
On November 7, 2014, however, the inmate attempted suicide and was initially placed in an
MHCB before being referred to DSH. From December 2014 through February 2015, he was
placed in the DSH APP and ICF programs; from February through July 2015 he was in another
DSH-ICF program. The inmate reported ongoing suicidal ideation throughout these DSH
placements. His diagnoses were Mood Disorder, NOS, and Antisocial Personality Disorder. He
returned to CDCR at the EOP level of care. In June 2016, he was again placed in an MHCB
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after being sent to an outside hospital following an alleged suicide attempt by drug overdose.
From late June 2016 until his death, the inmate was treated at the EOP level of care and had
diagnoses of Anxiety Disorder, NOS, and Borderline Personality Disorder (that was revised in
April 2017 to “Axis II Deferred”).
On May 9, 2017, the inmate was again sent to an outside hospital after reporting that he ingested
an unknown amount of Tylenol. Upon return to CSP/LAC the following day (May 10), he was
seen by a crisis clinician and stated: “I go 0 to 100, I want to be able to control some of (my)
problems.” According to the CDCR reviewer, “He requested to see his prior clinician and to be
referred to DSH. He refused to discuss why he was sent out to the hospital, saying he would
only talk to his prior clinician about what occurred. The evaluating clinician opined that the
inmate was appropriate to return to the STRH.” The inmate was screened by another clinician
upon entry into the STRH unit later that day (May 10), with the clinician noting: “The I/P has
been having a hard time coping since his cousin has been transferred (sic, had not occurred yet)
and has been engaging in maladaptive behaviors: smearing feces and ‘going suicidal.’” He was
not referred to an MHCB, although documentation erroneously indicated that he had been.
The following week on May 18, 2017, the inmate had an IDTT meeting in which the team
offered a number of incentives, including receiving a television, a package, and retaining him in
the MHSDS if he agreed to clean his cell, stop smearing feces and program appropriately. As
summarized by the CDCR reviewer, almost immediately after the IDTT meeting:
Clinical staff noted that “around 1650 hours,” the inmate was overheard talking
with custody staff, saying that he did not want to go back and clean the cell. He
argued that his cousin had made him promise before he transferred not to clean
the cell and as ‘other inmates told him to leave it, to stand up to custody.’ A short
time later the inmate told staff present that he felt suicidal, concerned that he
‘cannot keep his word’ with both his IDTT team and with the other inmates. He
told staff he had gone to his cell to start to clean it but was harassed by inmates
for ‘caving in.’ He was seen as reporting feeling suicidal to remove himself from
the situation. Clinical staff overheard the STRH sergeant state that the inmate
was to be ‘stripped out’ and placed in a holding cell, with someone assigned to
‘sit on him’ until the crisis clinician evaluated him.
The inmate was left unobserved and subsequently committed suicide.
The CDCR reviewer found that the inmate’s medical history was unremarkable and not
contributory to his suicide. Interviews with several STRH inmates indicated that the suicide was
not surprising. One inmate told the CDCR reviewer, “he was just tired… That he had ‘had it
with this.’ He gave someone a number to call if he died….and he asked me to pray for him.”
Another inmate reported the inmate asked for his prayers, said “he wasn’t feeling it, and was
tired of living.” As the CDCR reviewer concluded:
The inmate’s clinical presentation was very complex, and his behavior was rather
provocative…. The inmate was seen at times as having no mental illness, or
having only personality pathology, or only adjustment problems. His risk for
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suicide was typically viewed to be low, despite considerable evidence of acute
and chronic risk…. The suicide may represent that he had simply grown tired of
living, or was distressed about his cousin transfer, or is facing harassment from
other inmates, or was upset about not being able to return to his yard and
program. Perhaps being in conflict between his agreement with this team and
custody, and his agreement with his cousin and other inmates triggered the
hanging. Whatever the combination of reasons, it is clear that his actual risk for
suicide was often underestimated, and that leaving him unattended on May 18,
2017 was both unfortunate and not per policy.
The Suicide Report contained 25 recommendations for corrective action through a QIP:
1-7) The CDCR 837s submitted by responding staff identify numerous concerns
as noted throughout the review which present as policy and procedure violations.
8-12) Five nursing care concerns were identified. The concerns are listed above
and were considered contributory to the death.
13) Five mental health referrals were submitted regarding the inmate between
April 21, 2014 and April 28, 2014 for behaviors including fecal smearing,
mutism, visual hallucinations, and command auditory hallucinations. The referral
on April 24, 2014 was elevated to an emergent status, and a second emergent
referral was submitted on April 26, 2014. He was not seen until April 28, 2014
and then was found in no need for mental health follow-up (despite having been
placed in CCCMS on April 22, 2014). Per the Mental Health Services Delivery
System Program Guide, 2009 revision, “An inmate deemed to require an
emergent (immediate) referral shall be maintained under continuous staff
observation until evaluated by a licensed mental health clinician.” Further, the
clinical documentation on April 28, 2014 did not have a rationale for not
recommending a mental health follow-up, despite his recent erratic behavior and
change in LOC.
14) On April 21, 24, 26, and May 9, 21, 24, 2014, the inmate was observed
smearing feces on his body and around his cell. He reported acting in this way in
an effort to drive away ‘foreign entities’ and ‘evil shadows.’ Despite the severity
of his behavior he was not referred for inpatient services until May 26, 2014. The
clinical documentation during these encounters did not provide a clinical rationale
for not referring the inmate to a higher level of care.
15) While in a MHCB at CHCF from May 27, 2014 to June 2014, the inmate
smeared feces, was initially evasive about suicidal plans, and refused medications
offered to him. Despite this presentation, no discussion of involuntary
medications was found and there were no orders for psychiatric medications
made. He returned to his facility with no psychiatric medications.

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16) No SREs completed in 2014 documented an assessment of imminent risk
factors. Chronic and acute risk appeared to be underestimated, and safety
planning lacked in quality and continuity in these assessments.
17) Although it was mentioned in the DSH Psychiatric Discharge Summary
(dated July 13, 2015) that the inmate reported a desire to jump to his death upon
return to CDCR, a desire he reported over a number of months while at DSH, the
treatment team at LAC did not document this information in the next treatment
plan dated August 4, 2015, and the information was not included in the SREs
completed in subsequent months.
18) SREs completed on July 13, 2015, July 20, 2015, and July 22, 2015 were
administered by the same clinician, a clinician who used largely identical
information in each evaluation (e.g., states, ‘He doesn’t hearing voices [sic]’ in
each SRE). The clinician ignored or was unaware of statements made in ASU
pre-screening evaluations, screenings that indicated active suicidal planning and
intent. Acute risk is underestimated on each occasion (as low chronic and low
acute risk).
19) On December 23, 2015, the inmate requested to see a psychiatrist. Per
documentation, he was not seen for this request as he declined a prior psychiatric
appointment on December 16, 2015.
20) On June 4, 2016, the inmate reported taking 45-50 pills, type unknown. He
was sent to an outside hospital, medically cleared, and returned. He was
evaluated to be at low risk and low chronic risk, despite presenting with numerous
imminent risk factors, and despite endorsing suicidal intent, planning, and desire
to die. The action was deemed not to be a suicide attempt, though MHCB
placement was made.
21) On April 13, 2017, the inmate was seen by a psychiatrist, five days after he
threw feces on an officer’s furniture and belongings. The psychiatrist described
the inmate is experiencing ‘an episode of nonspecific anxiety that appears to have
resolved’ and discontinued his medication (Paxil). This evaluation appears
lacking in review of the inmate’s history of mental illness and did not give
rationale for not considering alternative medications.
22) Clinicians in the IDTT meetings on April 19, 2017 and May 18, 2017 did not
document awareness of the inmate’s prior suicidal crisis in October 2014, which
was precipitated by a reduction in level of care (from EOP to CCCMS), or
document knowledge of a prior suicide attempt (on November 7, 2014), in which
he attempted to hang himself in a holding cell after hearing his level of care
would not be increased back from CCCMS to EOP. Knowledge of these prior
events may have led to his risk being managed differently in the days leading up
to his death.

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23) The inmate’s actions on May 9, 2017 (overdose) appeared to have been
significantly minimized. The evaluating clinician (on May 10, 2017) justified a
rating of low acute risk despite the overdose and despite the inmate refusing to
speak about the event to the clinician. Following the evaluation, the inmate
answered pre-ASU screening questions with reports of distress and suicidal
ideation, indicating that his risk had not dissipated.
24) An IDTT meeting was held on the day of the inmate’s death to address fecal
smearing. This documentation suggests that his participation in the MHSDS was
somehow made contingent or related to him as contingent on his discontinuing
fecal smearing, ‘Patient will remain in the CCCMS program contingent on him
programming and not retaliating against staff.’ This is not a valid reason for
discontinuing services per program policy.
25) Custody documentation stated that a mental health supervisor told the inmate,
‘You’re not suicidal’ approximately one hour and 20 minutes prior to his death,
‘and would relay this information to the on-call psychologist’ (the crisis
clinician). The statement may have been provocative to the inmate or increased
his sense that he would be treated unfairly or dismissively.
In the third case (LAC 1), the inmate was found hanging from the ventilation grate by a sheet in
his EOP administrative segregation unit cell during the morning of August 4, 2017. His body
was found in the state of rigor mortis. He had entered the CDCR system on November 2, 2012
to serve a life sentence (with the possibility of parole) for first-degree murder with a firearm.
The inmate was transferred to CSP/LAC on May 22, 2017. He had 6 RVRs, the most recent of
which occurred on March 16, 2015 involving failure to return a library book. The inmate was
known to be gang-affiliated. In May 2013, he was endorsed to the SNY due to expressed safety
concerns. He had good family support, including letter correspondence, regular telephone calls,
and occasional visits from his parents. The inmate was never married and did not have any
children.
According to available records, the inmate was born and raised by his biological parents. He had
four other siblings. The inmate would later confide to a mental health clinician that he molested
one of his sisters as a teenager. He had a history of substance abuse and joined gangs at an early
age “because he yearned to belong and ‘to man up’.” He did not have any prior history of arrests
or convictions, and the instant offense involved the murder of a rival gang member when he was
17-years-old. He received some mental health treatment in the community during early
adolescence for depression.
Upon entry into CDCR, the inmate did not endorse any mental health symptoms and was not
initially placed in the MHSDS. However, on August 22, 2015, he was placed in administrative
segregation for safety concerns and subsequently observed “ramming his head against the wall”
and crying. He was placed in a MHCB and given the diagnoses of Adjustment Disorder with
Mixed Anxiety and Depressed Mood, and Antisocial Personality Disorder. The admission note
stated that: “He endorsed suicidal ideation passive. Anxiety/paranoia-large, depression-moderate,
recent meth use (3 days prior), concerned about recent events of his safety and inmate’s
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discovering of his sex activity. Despondent over sentence and shame about SNY and sexual
incident that’s been recently known by others/cellmate.” He was discharged from the MHCB on
September 4, 2015. Approximately a month later on October 2, the inmate was observed to be
making a ligature out of a sheet. He subsequently told a nurse that he was “ashamed of his
situation as homosexual” and that “suicide may be a better alternative than being in prison.” He
was again placed in an MHCB and discharged on October 23, 2015 at the EOP level of care. His
diagnoses were Adjustment Disorder, Methamphetamine-Induced Psychosis, Polysubstance
Dependence, and Antisocial Personality Disorder.
The inmate was admitted into a MHCB for the third time on November 10, 2015. He reported
that he had allegedly made a suicide attempt by jumping off his bunk but the ligature broke.
According to MHCB documentation, the inmate “endorses purposelessness in face of life term,
expects to go in front of the board in 19 years, but honestly believes he will likely commit
suicide rather than serve out sentence.” He was not referred to DSH because his mood and
paranoia had stabilized, he was medication-compliant, and engaged in out-of-cell activities. The
inmate was discharged from the MHCB on November 18, 2015 with diagnoses of SubstanceInduced Mood Disorder, Adjustment Disorder, and Antisocial Personality Disorder. During
most of 2016, medication compliance and EOP programming was viewed as inconsistent. His
auditory hallucinations were thought to be drug-related. Themes of loneliness and isolation from
his family reoccurred during clinical contacts, as did the questioning of his sexual identity. His
substance abuse increased throughout the year.
On January 30, 2017, the inmate reported that he cut himself the previous week while using
drugs, and a laceration was noted on his arm. He denied any current suicidal ideation and an
SRE was not completed. During the next few months, the inmate’s medications were adjusted
due to his frequent non-compliance. In a progress note dated April 10, 2017, his PC wrote that
“IP reports a low level of depression. IP shared that he recently had a visit from his father. IP
shared that his father made a comment that insinuated he was to blame for his parents’ divorce
and other family problems.” In a subsequent progress note dated April 24, his PC wrote that “IP
reports anxiety due to finding out that he will be transferred to another institution. IP continues
to struggle with substance abuse and recovery. He reports labile mood over the past week.” On
May 3, 2017, the inmate reported suicidal ideation during the previous weeks and months. An
SRE was completed and both his chronic and acute risk for suicide was rated as moderate. The
SRE did not contain a specific safety plan nor was the inmate referred to a MHCB.
Following his transfer to CSP/LAC on May 22, 2017, the inmate told a clinician that “I’m just
checking it out.…to be honest, if I don’t like it here then I’ll leave…taking it day by day.” A
subsequent Mental Health Evaluation dated June 2, 2017 noted that “IP appeared to have a
history of reporting SI and making para-suicidal gestures in an attempt to manipulate his
environment and fulfill certain needs/desires.” During the next few months, the inmate appeared
to adjust adequately to the facility, stating that he was now closer to his family. However, his
drug abuse continued, and his attendance in both individual and group therapy was sporadic.
The inmate attended his IDTT meeting on August 3, 2017, the day before his death, and the
summary stated:

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I/P stated the following: ‘It doesn’t really matter (CCCMS or EOP)….I don’t
think any of you care ……even if I told you (everything), you wouldn’t care…..I
think with the things I’ve done I don’t deserve to live.’ I/P appeared tearful at one
point during the meeting. Affect-dysphoric, irritable, restricted.
Shortly after the IDTT meeting, the inmate was placed in the EOP administrative segregation
unit due to safety concerns. He was not placed in a suicide-resistant new intake cell as required.
He committed suicide the following morning.
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and he did not have any serious
medical issues that were deemed to be contributory to his death. However, the CDCR reviewer
opined that the inmate had been contemplating suicide for several years before his death:
The weight of his lengthy term, the knowledge he molested his sister, his
participation in a murder, his struggle with addiction, and the shame or confusion
about his sexuality became too much to tolerate. He grew tired of prison and
increasingly felt like a burden to his family. Because his suicidal thinking and
suicide risk appeared chronically high, revealing itself back in a 2015 progress
note (‘I think of everything from hanging myself to slicing my wrists to
starvation. I go down the list and weigh my options’), it appeared to take very
little to make his final decision.
The Suicide Report contained four recommendations for corrective action through a QIP:
1) There was no SRE completed or any specifics about the safety plan mentioned
during a January 30, 2017 contact with mental health staff (at COR). This contact
was the result of a referral from nursing about lacerations on his arms from a
suicide attempt. In the May 3, 2017 SRE, the inmate reported suicidal ideation in
the past week and past few months, yet there was no individualized safety plan
included in the SRE to address his risk factors, warning signs or suicidal ideation.
A suicide risk safety plan should include individualized items to reduce and
manage suicidal ideation and risk factors.
2) Upon arrival at LAC, there was no SRE completed even though he reported
suicidal ideation in the month before his transfer and had a suicide attempt in
January 2017. Per the 2009 Mental Health Program Guide, ‘Any time the
medical and mental health screening of a new arrival to an institution indicates a
current or significant history, over the past year, of suicide risk factors, ideation,
threats, or attempts,’ a suicide risk assessment ‘shall be completed.’ Given his
history of suicide attempts, recently reported suicidal ideation in May 2017, and
warning signs and risk factors, and comments during August 3, 2017 IDTT about
not deserving to live, an SRE should have been completed.

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3) The inmate was discovered alone in a non-retrofitted intake cell within 12
hours of his initial ASU placement. Records identified a retrofitted intake cell
(D5-125) was vacant at the time of his ASU admission.
4) Based on reports submitted by responding staff, the inmate was discovered
cold to the touch, had a rigid jaw and fingers, and purple/blue fingertips. This
calls into question the thoroughness of the Security/Welfare checks completed
initially on Second Watch and completed during First Watch on the unit. The
officer who conducted the first two Guard 1 checks on Second Watch (0610 hours
and 0640 hours) reports cell 231 did not have a door tag that would assist in
identifying an inmate was assigned to the cell. The officer also reports he
observed the sheet covering the window but was able to see two empty beds
through a small space above the food port. Review of the Guard 1 ‘Rounds
Tracker Summary’ identifies all checks were completed. However, it appears the
making of a visual/physical observation of a living, breathing inmate, free from
obvious injury as required did not occur appropriately during either watch.
In the fourth case (LAC 8), the inmate was found hanging from the protective cover of the
smoke detector by torn strips of a mattress in his MHCB room during the late evening of
December 5, 2017. He had entered the CDCR system on February 29, 2000 to serve a life
sentence (with the possibility of parole) for second-degree murder with enhancement for
intentional discharge of a firearm causing great bodily injury/death. He was transferred to
CSP/LAC on December 28, 2017. The inmate incurred 19 RVRs during his 17-year
confinement, most recently for fighting on November 26, 2017. He had been gang-affiliated and
sought SNY status in July 2012 after being a gang-dropout. He also spent considerable time in
administrative segregation during 2016 and 2017 due to safety concerns over an accumulating
drug debt. The inmate was unmarried and had a young son. He did not have any recent family
support and had stopped communicating with his family a few years earlier because he did not
want to be a burden to them any longer.
According to limited available records, the inmate was raised by his mother following the
divorce of his parents when he was a young child. His father subsequently committed suicide.
He had four siblings and was reportedly physically abused by his aunt and uncle. He began
experiencing substance abuse as a teenager and reportedly overdosed on cocaine in 1996. He
had numerous juvenile and adult arrests and convictions, and due to his illegal entry into the
United States from South Vietnam, had an active Immigration and Customs Enforcement
detainer.
The inmate did not have a history of mental health treatment in the community. However, when
he entered the MHSDS system in December 2016 at the MHCB level of care for suicidal
ideation, he reported to a clinician that he first started experiencing symptoms of depression and
anxiety when immigrated to the United States at age 14. He also reported a suicide attempt as a
teenager. The inmate’s initial diagnoses in the MHCB were Depressive Disorder, NOS, and
Psychotic Disorder, NOS (rule in/out). He was subsequently released from the MHCB on
January 6, 2017 with a diagnosis of Major Depressive Disorder with Psychotic Features. He was
also assessed to have both a “moderate” chronic and acute risk for suicide. However, three days
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later on January 9, the inmate was again admitted into an MHCB for suicidal ideation and
command auditory hallucinations telling him to hang himself. He also reported feeling distanced
and disconnected from his family, as well as experiencing safety concerns due to drug debts.
The inmate was also using methamphetamine on a regular basis during the previous two weeks.
His diagnoses were revised to Substance-Induced Psychosis and Depressive Disorder, NOS. He
was discharged at the EOP level of care on January 17, 2017.
From January 17 through May 18, 2017, the inmate received treatment in the EOP administrative
segregation unit at CMC. He continued to report on-going passive suicidal ideation without a
plan but remained relatively stable on his medication. On May 11, he was put up for transfer to a
Level 4 facility and reported a few days later that he was actively suicidal with a plan he would
not disclose. He was placed in a MHCB on May 18. While in the MHCB, the inmate was
referred to a DSH-ICF program on May 30 and subsequently transferred to that program on June
22. He remained in the ICF program until November 16, 2017 when he was discharged to SVSP
at EOP level of care. Although remaining medication-compliant in the ICF program, the inmate
frequently refused any in-patient treatment groups, minimized his substance abuse issues, and
had poor insight into his mental illness.
While awaiting transfer to CSP/LAC on November 28, 2017, the inmate superficially cut his
right forearm because he was depressed and anxious over safety concerns related to the transfer.
The required SRASHE was not completed and he was subsequently transferred and cleared for
GP housing. Several days later on December 3, the inmate made suicidal statements to staff and
superficially cut his right foot. A SRASHE was completed and he was placed in the MHCB. He
told a clinician that “Wherever I go, they want to get me, it happened already here, I’m tire (sic)
of running away.” The inmate told a clinician the following day (December 4) that although he
did not want to die, he was experiencing both depression and anxiety over fears that he would be
attacked in the yard. His diagnoses were changed to Adjustment Disorder with Mixed Anxiety
and Depressed Mood; Psychotic Disorder with Hallucinations. He was subsequently
downgraded from Suicide Precaution status to 30-minute observation with “full-issue” clothing
without any documented clinical rationale for the decision. Later that day, the inmate was found
to be “braiding a towel” into a ligature and placed on Suicide Watch status, but the clinician
inadvertently allowed the “full-issue” order to remain in effect, resulting in confusion amongst
nursing staff. The following day (December 5), another clinician downgraded the level of
observation to Suicide Precaution status, with the “full-issue” order remaining in effect. There
was no progress note documenting the clinical rationale for the decision. The inmate was found
hanging later that evening. During subsequent inspection of the cell, a razor blade was found
which the inmate had apparently utilized to tear the mattress cover utilized in the hanging.
The CDCR reviewer in this case did not cite any specific precipitating factors that were known to
staff indicating that the inmate was contemplating suicide, other than the obvious fact that he was
in the MHCB for suicidal ideation related to increased depression and anxiety surrounding his
safety concerns. The reviewer suggested that:
His cultural differences as a Vietnamese male further complicated his ability to
gain insight into his mental illness and understanding how illicit substances
further exacerbated his symptoms; it was not culturally sanctioned in his ethnic
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group to reach out for mental health services or even to acknowledge a problem.
His aloneness and isolation further escalated as time passed and he began to feel
targeted for death by other inmates due to his mounting drug debts, and safety
concerns as result of chronic substance abuse. Unfortunately, his inability to
adequately express himself and his fears due to cultural background, often
resulted in staff underestimating his expressed psychiatric symptoms or believing
he was less than truthful about his cultural and perceived enemy concerns. In the
end, these factors likely played a heavy role in his decision to end his life.
The Suicide Report contained 12 recommendations for corrective action through a QIP:
1) The MHCB discharge SRE conducted at COR on January 6, 2017 was very
basic and non-descriptive. The inmate had been hospitalized in the MHCB for
approximately three weeks and there was minimal information in the SRE to note
hospital course. His chronic risk (8 of 16 factors positive) was noted to be low,
which was notable as he averaged approximate 50% for both categories. Yet,
there was minimal discussion in the justification/safety plan sections for various
ratings outside of the basic listing of factors. Acute risk was noted as low because
the inmate had denied current suicidal ideation and homicidal ideation and a
current desire or wish to die. Minimal protective factors were noted (4 of 12).
Additionally, there was no individualization or integration regarding specific
triggers which might necessitate a return to MHCB.
2) A SRASHE completed on January 23, 2017 at CMC post-discharge from
MHCB to ASU EOP was problematic as a contained no real justification of risk
and no viable safety plan. The safety plan section contained a listing of chronic
risk factors which were listed in the wrong section of the SRASHE, and were
neither individualized nor integrated.
A second SRASHE completed by the same PC at CMC on April 19, 2017 also
was not well conceptualized. On this SRASHE, the PC reduced risk level for
both chronic and acute risk to low, without an adequate explanation for the
change. Additionally, the safety plan section noted: ‘see SRE’ without further
explanation.
A SRASHE completed on May 30, 2017 as part of the MHCB discharge at CMC
was problematic. Some acute risk factors were missed (perception of loss of
social support; safety concerns) and some protective factors were not documented
correctly (family support; positive coping/conflict resolution; insight into
problems). The risk factors/justification section largely focused on the inmate’s
prior self-harm in the community without adequately incorporating the multitude
of acute and chronic risk factors in prison. Additionally, most of the information
in the safety/treatment plan section would have been more accurately placed in
the risk level/justification section. Outside of the referral to the ICF program,
there was minimal information contained in the safety plan about how the

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institution’s mental health staff was managing the inmate’s depression, anxiety,
fear over drug debts, and feelings of isolation.
3) The SRASHE written November 21, 2017 at SVSP was missing multiple
elements, including which acute and chronic risk factors the inmate had, plus
protective factors were missing. Additionally, both the justification of the risk
and safety/treatment planning sections contained minimal documentation. There
was no integration of risk factors. The C-SSRS section was also not fully
completed.
There was another SRASHE written by the same clinician on November 27, 2017
after the inmate had been involved in a fight with another patient. This SRASHE
was also problematic as the clinician missed numerous acute risk factors for the
inmate, including recent depressive and psychotic symptoms, recent substance
abuse, loss of social support, interpersonal isolation, receiving bad news (PIP
discharge with pending transfer to Level 4 prison), and safety concerns.
Therefore, her conclusion of a low acute risk was largely underestimated.
4) The SRASHE completed on November 29, 2017 upon transferred to LAC was
inadequate. The listing of acute risk factors was missing in the document and the
protective factors were overstated (e.g., family support, insight, and positive
coping skills). Additionally, there was minimal justification of risk outside a
basic listing of factors without integration, and the safety/treatment plan section
was underdeveloped. There was no indication the clinician had received any of
the records from the PIP hospitalization. There was no mention of the fact the
inmate had cut himself the day before, which could escalate his risk for suicide.
The pre-MHCB admission SRASHE completed on December 3, 2017 was
problematic: the clinician listed multiple protective factors in the safety plan
which were likely confused with another inmate; for example, including contact
with a daughter and grandchildren (this inmate had a son he was not in contact
with), and completing his GED (which he had already possessed). The inmate’s
individualized risk factors, including his recent episodes of self-cutting and selfreported safety concerns, and the pre-discharge fight at SVSP were not well
integrated in the justification of risk nor the safety/treatment plan.
5) No SRASHE was found in EHRS documentation for November 28, 2017 after
the inmate superficially lacerated his right forearm before leaving SVSP.
Program Guide 12-10-8 states: ‘At minimum, a written suicide risk evaluation
using a SRE shall be completed: every time an inmate has an individual face-toface evaluation for suicidal ideation, gestures, threats, or attempts by a clinician
trained to complete the SRE.’ Given the inmate had not previously evidenced
cutting behavior during his time in CDCR, this noted a change from previous
level of functioning so, at a minimum, a SRASHE should have been completed
prior to the discharge by the senior psychiatrist involved.

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6) Clinical documentation by the inmate’s ASU EOP PC at CMC (January-May
2017) was frequently inadequate in that most of the clinician’s progress notes did
not contain complete mental status, nor a specific plan which noted weekly
progress. Frequently, the plan/disposition in the note was to ‘continue EOP.’
7) When the inmate arrived at LAC, his psychiatric medications (Remeron and
Zyprexa) were not reconciled, resulting in no psychotropic medication prescribed
from November 28-December 4 (day before hanging). The inmate did receive
Remeron on December 5, but the Zyprexa had yet to be reordered for him and as
a result it was not given. During this time period, mental health staff were
inaccurately documenting that he was medication compliant, when in actuality he
was not prescribed psychiatric medication for seven days.
8) LAC mental health documentation in MHCB was sparse and inadequate. The
clinician who reduced the level of observation on December 4 from Suicide
Precaution after less than 24 hours in MHCB did not specify the rationale for such
a quick removal of precautions. The same afternoon, there was inadequate
documentation for the reason the inmate was placed on Suicide Watch by the oncall psychiatrist (there is no mention of the inmate braiding a towel documented
until the following day). Similarly, the level of observation was decreased to
Suicide Precaution on December 5, and no rationale was provided for that
reduction in level of observation either. For subsequent changes of orders, a new
face sheet was not produced for the patient’s door which could have incorrectly
contributed to other staff giving the inmate access to privileges he did not have,
including clothing and reading material which may have been used to partially
block his door so that he could construct his noose. Given LAC went live in
EHRS at the end of October 2017, the confusion around EHRS orders for Watch
and Precaution could be part of a training issue.
9) During the course of the on-site review at LAC, it was determined the inmate
was found in possession of a state-issued razor that appears to have been utilized
to cut strips of material from the safety mattress used to construct the ligature.
10) LAC Suicide Watch/Suicide Precaution documentation inconsistent with
orders or policy.
11) LAC/SVSP Inter-Facility and Intra-Facility Transfer Process: Failure to
follow procedures: EHRS workflow 0100-031 for ambulatory R&R: a)
Encounter at the sending institution was closed prior to transfer, b) Reconciliation
of medications could not be done by Mental Health, c) Psychiatric medication not
ordered at receiving institution for seven days (11/28/17 – 12/04/17: Patient
without psychiatric medications for seven days).
12) LAC – Issues in EHRS with no Suicide Watch/Suicide Precaution orders.
The reviewer was shown a copy of the orders page from the inmate’s door, where
the previous order had been crossed out and initialed by a MHCB psychologist
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after the inmate was placed on Suicide Watch at 1555 hours by the on-call
psychiatrist. However, the MHCB staff did not delete or alter the part of the order
in EHRS which states: ‘Patient to be given full issue unless otherwise specified in
this order by the provider’ when he was placed on Suicide Watch. This may have
added to the confusion by all staff (custody, mental health and nursing alike) who
may have been following doctors’ orders that appeared contradictory.
15)

California Correctional Institution (CCI)

Inspection: November 16-17, 2017 (previous suicide prevention audit was on April 26-27,
2016). CCI housed approximately 3,849 inmates at the time of the on-site assessment.
Screening/Assessment: This reviewer observed a few new admissions during the intake
screening process in the D-Yard Clinic on November 17, 2017. (Of note, R&R was conducted in
several different yards/facilities at CCI.) The nurse was observed to be asking all of the
questions and correctly entering information into the EHRS. However, there was no door to the
nurse’s office and the desk where the newly-admitted inmates were positioned was adjacent to a
high-traffic area, with other staff and inmates passing through, creating both excessive noise and
absence of privacy and confidentiality. This reviewer was informed that the nurse’s offices in
both the C-Yard Clinic and E-Yard Clinic also did not have doors. (During the preceding
assessment, this reviewer observed new intake screening in the B-Yard Clinic and found that a
TTM had been installed to ensure privacy and confidentiality, and the door to the nurse’s office
remained closed during the intake screening process.)
In addition, this reviewer observed daily rounds by a PT in the administrative segregation unit
(B-8) on November 16. The unit housed GP, 3CMS and EOP inmates. The rounds were
unremarkable, and the PT was observed to be correctly completing the Psych Tech Daily Rounds
Forms and entering the information into the EHRS for MHSDS inmates.
Housing: CCI had eight of its 16 OHU cells designated to temporarily house inmates with
mental illness and/or requiring suicide observation. These OHU cells were designated as
alternative housing and required 1:1 observation prior to transfer to a MHCB unit. The cells
had either fixed beds or stack-a-bunks. In addition, as observed during the previous assessment,
inmates awaiting transfer to an MHCB and housed in the OHU on 1:1 observation were not
automatically placed in a safety smock. Rather, because they were required to be observed on a
continuous 1:1 basis, pursuant to a LOP (Volume 12: Mental Health Services, Chapter 5.1:
“Mental Health Crisis Bed Program, Alternative Housing-Mental Health”), each inmate was
“provided with a safety mattress, sheets, safety blanket, state issued clothing, including pants,
shirt, socks, underclothes, reading materials, hygiene items and a prescribed healthcare appliance
as clinically indicated as per Policy 12.05.301.” Such a policy and practice continued to be very
commendable.
From August 1 through November 4, 2017, there were approximately 127 inmates placed in
alternative housing, and the vast majority (87 percent) was released within 24 hours. Only a
handful of inmates were housed over 48 hours, and the overall length of stay for the 127 inmates
was 19 hours. Almost all inmates were subsequently transferred to a MHCB.
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Finally, the B-8 administrative segregation unit still contained three retrofitted new intake cells
(A103-A105). Although there were not any new intake inmates observed in unsafe non-intake
cells, a custody supervisor informed this reviewer that the unit exceeded its new intake cell
capacity approximately every one to two weeks, and that a recommendation had been made in
November 2016 to create more retrofitted new intake cells. It was unclear if a work order had
been generated regarding this recommendation.
This reviewer also found another problematic practice in the administrative segregation unit.
Five cells (101 through 105) in B-Section did not contain any bunks. This reviewer was
informed that the bunks were removed several years ago when the unit was used for the special
management of SHU inmates. Currently, any inmate placed in these cells was not provided a
bunk. These cells should be taken off-line until permanent bunks are installed.
Observation: Because CCI did not operate a MHCB unit, all suicidal inmates were required to
be supervised on 1:1 observation until they were transferred to a MHCB. No other levels of
observation were permitted within the OHU. During the assessment, this reviewer only observed
medical patients in the OHU.
Finally, a review of Guard One data for a recent 24-hour period found 98-percent compliance
with the required checks not exceeding 35-minute intervals in the administrative segregation
unit.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS for the period of September 1
through October 31, 2017. This reviewer’s sample EHRS review of 60 emergency referrals for
suicidal ideation/behavior found that clinical staff completed the required SRASHEs in 95
percent (57 of 60) of the cases.
This reviewer did not review discharging SRASHEs at CCI because the assessments were
conducted by mental health clinicians at other MHCB facilities.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 51 cases of patients discharged from a
MHCB or alternative housing placement that were returned or transferred to CCI and not
transferred to the administrative segregation unit (where observation at 30-minute intervals was
required) from May through October 2017. The review found that 94 percent had Page One of
the “Discharge Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental
health clinicians, with the vast majority (73 percent) of the custody checks recommended for 48
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hours by clinicians. In addition, 92 percent of the “custody check” forms (Page Two) were
completed correctly by correctional staff at 30-minute intervals.
Intervention: Housing units toured by this reviewer all contained an emergency response bag
that included a micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (August through
October 2017) found that quorums were not achieved in any of the meetings. The meeting
minutes were otherwise unremarkable.
Training: According to training records, 91 percent of custody and 100 percent of nursing staff
was currently certified in CPR. In addition, approximately 98 percent of custody, 90 percent of
medical, and 86 percent of mental health staff completed the annual suicide prevention block
training during 2016. Finally, as of October 2017, 100 percent of mental health clinicians had
completed the SRE mentoring program, 100 percent had completed the seven-hour SRE training
program, and 88 percent had completed safety plan training.
Recent Suicides: CCI experienced one inmate suicide during the review period. In that case
(CCI 1), the inmate was found exsanguinated in his SNY cell during at approximately noon on
December 26, 2017. The inmate had entered the CDCR system on January 21, 2004 to serve a
21-year and four-month sentence for carjacking and attempted robbery. He was transferred to
CCI on May 3, 2017. Of note, the inmate was housed in a contracted California Out-of-State
Correctional Facility from April 2009 through May 2017. He had eight RVRs during his
confinement, the most recent of which occurred on October 28, 2016 for battery on another
inmate. The inmate was known to be gang-affiliated and was placed in SNY in March 2013 after
becoming a gang dropout. He had a detainer from Immigration and Customs Enforcement and
was expected to be deported upon his release from CDCR. The inmate had good family support
through letter correspondence with his parents and siblings. He also had periodic visits,
including one as recently as December 2, 2017 from his niece. The inmate was unmarried and
had a 14-year-old daughter.
According to limited available records, the inmate was the youngest of eight siblings and initially
raised by both parents in Mexico. He came to the United States in 1993 at the age of 12. The
inmate initially lived with one of his brothers but was living with an aunt at the time of arrest for
the instant offense. The inmate did not complete high school and was sporadically employed.
He had a history of substance abuse as a teenager but did not report or have a documented
history of mental illness in the community. Throughout his CDCR confinement, the inmate did
not report any mental health issues and was not placed in the MHSDS. He never threatened
suicide nor reported any history of suicidal behavior.
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and he did not have a significant
medical history that was found to be contributory to his death. Posthumous interviews with staff
and inmates found that the inmate was quiet, well-liked, and did not give any indication that he
was depressed or suicidal. However, a few inmates opined that he had sporadically used illegal
drugs and it was possible that these substances contributed to the suicide.
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The Suicide Report did not contain any recommendations for corrective action through a QIP.
16)

Deuel Vocational Institution (DVI)

Inspection: December 5-6, 2017 (previous suicide prevention audit was on August 30-31,
2016). DVI housed approximately 2,202 inmates at the time of the on-site assessment.
Screening/Assessment: This reviewer observed two new admissions during the medical intake
screening process in the RC on December 6. The nurse’s office had been recently renovated, and
the door was closed during the intake screening process with an officer stationed outside, thus
ensuring both privacy and confidentiality. However, both intake screenings were problematic
because the nurse did not ask all of the mental health and suicide risk questions on the “Initial
Health Screening-Male” forms. Following the process, this reviewer conversed with the nurse
and inquired why all of the questions were not asked to either inmate. The nurse responded by
stating that an “abbreviated” screening was completed if the county transfer form did not include
any documentation of prior mental health or suicide history. Such a response was problematic
for several reasons, including the fact that CDCR policy required that all questions be asked; an
individual could certainly become suicidal following their county jail confinement and transfer to
CDCR; and despite not asking all of the required questions, the nurse entered “no” to all mental
health and suicide risk responses in the EHRS for both inmates (DV1 1 and DVI 2).
The following day (December 6), this reviewer observed the mental health diagnostic testing in
the RC on one case (DVI 3). The clinician completed an extremely thorough examination of the
inmate who had entered DVI a week earlier on November 30. He self-reported being currently
depressed, as well as being previously diagnosed with Bipolar and Schizoaffective Disorders, as
well as ADHD. During a previous CDCR term, he had been treated at the EOP level of care.
The inmate also had a history of five prior suicide attempts. He had also been suicidal in the
county jail and placed on suicide precautions for ten days in August 2017. The inmate admitted
to being suicidal when he first arrived at DVI on November 30, claiming that he had thoughts of
jumping off the second tier of his housing unit. Although not currently suicidal on December 6,
he admitted having fleeting thoughts of suicide during the past few days. The inmate also
complained of auditory hallucinations. The clinician spent well over 90 minutes evaluating the
inmate, completing the MH Screening Interview, SRASHE (finding both “high” chronic and
acute risk for suicide), MH Consult Inpatient, and mental health primary clinician (MHPC)
Initial Assessment forms. The inmate was subsequently referred to a MHCB.
The only major concern with the case was that the inmate had self-reported much of the above
information during the intake screening process on November 30. Despite the abundance of
such concerning information, he was not seen by a mental health clinician until December 6.
Finally, daily PT rounds in one of the administrative segregation units (L-1) were observed on
December 5. The rounds were unremarkable, and the PT was observed to be correctly
completing the Psych Tech Daily Rounds Forms and entering the information into the EHRS for
MHSDS inmates. Of note, PT rounds were being performed twice a day following the most
recent inmate suicide in the L-1 Unit in November 2017.
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Housing: DVI had 24 OHU rooms, ten of which were designated as alternative housing to
temporarily house inmates with mental illness and/or requiring suicide observation. Each of the
rooms had a bunk and inmates were required to be under 1:1 observation prior to transfer to a
MHCB. On occasion, TTA cells were also designated for alternative housing. From September
1 through November 30, 2017, there were approximately 128 inmates placed in alternative
housing, with the vast majority (84 percent) released within 24 hours. No inmates were housed
over 48 hours, and the overall length of stay in alternative housing for these 128 inmates was 16
hours.
Finally, the administrative segregation unit (L-1) housed GP, 3CMS, and EOP inmates. The unit
originally had five retrofitted new intake cells, but that number had been increased to 11 in the
past year. However, the 11 new intake cells (138 through 148) were not completely suicideresistant. One cell (148) had a gap between the bunk and wall, and all 11 cells had ventilation
grates with holes in excess of 3/16-inch in diameter. In addition to these 11 new intake cells not
being completely suicide-resistant, there were three new intake inmates observed in unsafe nonintake cells. This finding was particularly problematic because two inmates (DVI 4 and DVI 5)
who committed suicide in the administrative segregation unit in October and November 2017
were not placed in suicide-resistant new intake cells upon admission.
Of note, the other segregation unit (K-1) had been closed for renovation since spring 2016 and
was scheduled to be reopened in early 2019. The K-1 Unit had contained 27 retrofitted suicideresistant cells for new intake inmates.
Observation: Because DVI did not operate a MHCB unit, all suicidal inmates were required to
be supervised on 1:1 observation until they were transferred to a MHCB. As noted above, most
inmates were housed in the OHU. No other levels of observation were permitted within the
OHU for suicidal inmates.
A review of Guard One data for a recent 24-hour period found almost 100-percent compliance in
the L-1 administrative segregation unit with the required checks not exceeding 35-minute
intervals.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS from September 1 through
November 30, 2017. This reviewer’s sample EHRS review of 40 cases of emergency mental
health referrals for suicidal ideation/behavior revealed that mental health clinicians completed
the required SRASHEs in only 85 percent (34 of 40) of the cases.
In addition, this reviewer examined ten SRASHEs of inmates initially placed in alternative
housing for suicidal ideation at DVI, but their MHCB referrals were subsequently rescinded.
The review found that many of the SRASHEs did not contain safety plans to reduce future SI.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.

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A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 92 cases of patients discharged from a
MHCB and alternative housing that returned or transferred to DVI and were not transferred to
administrative segregation (where observation at 30-minute intervals was required) from June 1
through November 30, 2017. The review found that 85 percent had Page One of the “Discharge
Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental health clinicians,
with the vast majority (75 percent) of the custody checks recommended for 48 hours by
clinicians. In addition, 88 percent of the “custody check” forms (Page Two) were completed
correctly by correctional staff at 30-minute intervals. Most of the deficiencies cited were related
to clinicians not signing documentation and/or gaps in the observation by correctional staff.
Intervention: All housing units toured by this reviewer contained an emergency response bag
that included a micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (September through
November 2017) found that quorums were only achieved in one of the meetings (November). Of
note, the monthly meetings averaged between 20 and 26 participants. Meeting minutes were
otherwise unremarkable.
Training: According to training records, 96 percent of custody staff and 97 percent of medical
staff were currently certified in CPR. In addition, 98 percent of custody staff, 86 percent of
medical staff, and 79 percent of mental health staff received annual suicide prevention block
training during 2016. Finally, as of November 2017, 93 percent of all mental health clinicians
had completed the SRE mentoring program, 74 percent had received the seven-hour SRE
training, and 19 percent had completed safety plan training.
Recent Suicides: DVI experienced four inmate suicides during the review period. In the first
case (DVI 6), the inmate was found hanging from the window bar by a sheet in his RC-SNY cell
during the late evening of March 12, 2017. The inmate entered the CDCR system through the
RC at DVI on January 19, 2017 to serve a 24-year and eight-month sentence for rape, false
imprisonment, and assault (of his girlfriend). During his 53-day confinement, he did not have
any RVRs. The inmate was not known to be gang-affiliated. He was unmarried and had a 13year-old daughter. There was evidence of family support through letter correspondence found in
the inmate’s cell. There were also two brief notes found in his cell allegedly from other inmates
indicating possible extortion due to their knowledge of his commitment offense.
According to limited available records, the inmate was born in Mexico and raised by his parents
until he illegally entered the United States in 2007 in search of employment. His mother died in
2014 and he did not have any contact with his father. There was no record of siblings. He
denied any dependence on alcohol or illegal drugs. He did not have any prior criminal history.
There were no records indicating that the inmate ever received mental health treatment in the
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community. Upon entry into the CDCR, the inmate screened negative for any mental health
issues and was not placed into the MHSDS. However, a mental health referral dated January 19,
2017 from the intake nurse indicating that the inmate “got sentenced to 24 years. New
commitment, feels depressed,” was apparently misplaced and not available to the clinician
completing the diagnostic testing the following day (January 20).
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and he did not have any medical
issues which were felt contributory to his death. However, the reviewer noted that the inmate
was possibly a victim of extortion from other inmates due to knowledge of his crime, and
although it was not known if he succumbed to their demands, “the pressures of these threats
likely aggravated the existing presence of his underlying despair. The inmate did not leave a
suicide note or any other insight into his final decision to end his life; although the overwhelming
fear of his extensive sentence and the desperation for his safety are plausible contributory
factors.”
The Suicide Report contained one recommendation for corrective action through a QIP:
1) The mental health referral submitted on January 19, 2017 was not received by
the mental health clinician. Mental health clinician had seen the inmate on
January 20, 2017, but the session was not in response to the referral, rather the
inmate was seen per the routine intake process. The referral was determined
‘completed’ and closed in the system by an office technician who mistakenly
associated the mental health session with the referral. The office technician
printed the mental health clinicians name on the ‘received by’ and the ‘assigned
to’ line on the referral; therefore, it could be misinterpreted as a signature
indicating the referral was complete and clinician have seen the inmate.
While with the implementation of the EHRS on March 7, 2017, all health care
referrals will follow an electronic process in which the referral is sent directly to a
clinician, all referrals made by non-health care staff will continue to use a paper
referral process. All referrals will continue to be scanned into the EHRS and an
office technician will assign the referral to the appropriate clinician. It is
important that all staff who are responsible for assigning referrals ensure they
accurately identify themselves as a person who receive the referral and the mental
health clinician assigned to the referral.
In the second case (DVI 7), the inmate was found hanging from the ladder by a sheet in his RCSNY cell a few minutes after midnight on April 19, 2017. The inmate entered the CDCR system
through the RC at DVI on March 10, 2017 to serve a three-year sentence for corporal injury to
his girlfriend. During his 40-day confinement, he did not have any RVRs. The inmate was not
known to be gang-affiliated. He had family support through letter correspondence with his
mother and girlfriend. The inmate was unmarried and had four children from prior relationships.
According to limited available records, the inmate was born and raised by his parents until he
was approximately 15-years-old when he left home in order to obtain a job and provide financial
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support to his newborn baby. He became employed as a seasonal laborer. The inmate also
began using illegal drugs on a daily basis as a teenager. He had limited juvenile and adult
criminal histories. There were no records indicating that the inmate ever received mental health
treatment in the community. Upon entry into the CDCR, he screened negative for any mental
health issues and was not placed into the MHSDS. The inmate denied any current or prior
history of suicidal ideation or behavior.
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and he did not have any medical
issues which were felt contributory to his death. Of note, a cellmate interviewed following the
suicide alleged that the inmate had attempted suicide on three occasions during his brief DVI
confinement. Two of these alleged incidents were not known to CDCR staff; there was an
allegation that the third alleged suicide attempt by cutting was known to custody staff but did not
result in a mental health referral. This allegation was pending further investigation. Several
items of property and suicide notes were found in the inmate’s cell. According to the CDCR
reviewer, “His property had various items with themes of death, regret, a sense of being a burden
to his family, and anguish over his girlfriend. He wrote several goodbye letters found within his
belongings. These letters suggested that he had been ruminating about finding the means to end
his personal agony and guilt over the pain he felt he inflicted on others.”
The Suicide Report contained two recommendations for corrective action through a QIP:
1) Custody staff responding to the incident failed to respond with the appropriate
cut-down kit but rather the cut-down tool and Ambu bag. California Code of
Regulations (CCR), Title 15, Section 3365 (c) states in part, “A cut-down kit shall
be immediately assessable on each unit and shall be used by staff in case of an
attempted suicide by hanging.”
2) Custody staff responding to this incident failed to articulate whether or not the
body weight of the inmate was supported prior to being cut down. The Suicide
Prevention lesson plan explains emergency response procedures and expectations
during medical emergencies. The primary objective is to preserve life and
specifically states custody is to relieve tension and cut the noose above the knot.
In the third case (DVI 4), the inmate was found hanging from the ladder by a sheet in his RCadministrative segregation cell during the late evening of October 29, 2017. The inmate entered
the CDCR system through the RC at DVI for a third term on September 19, 2017 to serve a oneyear and four-month sentence for possession of a weapon by a felon. During his 41-day
confinement, he did not have any RVRs. The inmate was not known to be gang-affiliated while
in CDCR but was associated with gangs in the community. On October 27, 2017, he requested
to be housed in protective housing due to safety concerns. The inmate was subsequently housed
in the RC section of the administrative segregation unit. He was not placed in a suicide-resistant
new intake cell. The level of family support, if any, was unknown. The inmate was unmarried
and did not have any children.

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According to limited available records, the inmate was born and raised by his parents in Laos
until he was approximately 16-years-old when he immigrated to the United States. His closest
family members included a mother, two older brothers, a younger brother, and at least two
sisters. Available records suggested that he lived alone, did not complete high school, and was
sporadically employed. The inmate reported that he began using illegal drugs as an adult. His
criminal history began at age 19 and included two previous CDCR terms. There were no records
indicating that the inmate ever received mental health treatment in the community. Upon entry
into the CDCR, he screened negative for any mental health issues and was not placed into the
MHSDS. The inmate denied any current or prior history of suicidal ideation or behavior. On
October 25, 2017, however, the inmate answered, “a little” when asked by a PT completing the
ASU Screening Questionnaire whether he was nervous, hopeless, restless or fidgety, depressed,
everything was an effort, and worthless. He was seen by a mental health clinician several hours
later, denied any current suicidal ideation, presented with an adequate mental status, and assessed
as not being in need of any further mental health services. It was later determined that the
clinician had not reviewed the ASU Screening Questionnaire.
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and he did not have any medical
issues which were felt contributory to his death. Two suicide notes, as well as a Health Care
Services Request form, dated October 26 and reporting that he was depressed and needed to see
a mental health clinician, were found in his cell. The request form had not yet been submitted
and, therefore, unknown to staff. According to the CDCR reviewer, “information gathered
during the course of this review suggests fear of his safety, his impending release to the
community on December 13, 2017, and his fear of rejection by his family appeared to be
plausible contributory factors to the inmate suicide.”
The Suicide Report contained two recommendations for corrective action through a QIP:
1) In an ASU Screening Questionnaire performed by a psychiatric technician on
October 25, 2017 at 0955 hours, the inmate, a non-participant in the MHSDS,
stated that he felt nervous, hopeless, restless or fidgety, depressed, or worthless
within the past 30 days. At 1329 hours the same day, the inmate was interviewed
by a mental health clinician who did not provide any documentation referencing
the information contained in the ASU Screening Questionnaire, despite this
information being readily available to the clinician in the Electronic Health
Record System (EHRS).
2) Although not found to be a contributing factor to the suicide, a review of the
SOMS identified that the inmate had not been housed in a retrofitted intake cell
upon his initial placement in ASU.
In the fourth case (DVI 5), the inmate was found hanging from the ladder by a sheet in his
administrative segregation unit cell during the evening of November 17, 2017. The inmate
entered the CDCR system through the RC at DVI on September 20, 2017 to serve a 16-month
sentence for evading or attempting to evade a peace officer. During his 59-day confinement, he
did not have any RVRs. The inmate was known to be gang-affiliated. He had family support
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through letter correspondence with his mother and grandmother. The inmate was unmarried and
had a 4-year-old daughter.
According to limited available records, the inmate and five siblings were raised by both his
mother and grandmother. Information regarding his father was unknown. The inmate reported a
history of substance abuse beginning at age 12. He had a minimal employment history. He had
an extensive juvenile history and was in and out of juvenile facilities from ages 12 through 17.
The inmate reported a childhood diagnosis of ADHD and inconsistently took medication until
age 17. He did not report any other mental health treatment in the community.
Upon entry into CDCR, the inmate reported a prior suicide attempt by a heroin overdose in 2016.
He denied any current thoughts of suicide but indicated to the intake nurse that he was “feeling
down or depressed more than half the time in the last two weeks.” The inmate received
diagnostic testing two days later on September 22 and again reported some depression and the
prior suicide attempt (subsequently telling another clinician the incident was accidental). As a
result, he was referred for further mental health assessment. Several days later on September 27,
another mental health clinician completed both a SRASHE and MHPC Initial Assessment. The
SRASHE noted that the inmate had “fleeting thoughts of suicidal ideation within the past week,”
but he was not currently suicidal. The mental status exam portion of the initial assessment found
that the inmate had poor memory, distraction, fair judgment, a tendency to minimize his
problems, had the need for mental health treatment, and a below normal intelligence. He denied
any current mental health issues, a desire to be on psychotropic medication, or willingness to
participate in the MHSDS. The clinician’s initial diagnosis was Intermittent Explosive Disorder,
Polysubstance Dependence, and Antisocial Personality Disorder. The assessment noted that the
inmate “denies any mental health issues and none were noted by this writer.” He was not placed
in the MHSDS.
On November 15, 2017, the inmate was placed in administrative segregation due to safety
concerns based upon expectations that he would be harmed after dropping his gang-affiliation.
In addition, he was also interviewed by his CC I that same day and expressed concerns that a
previous juvenile arrest and conviction for child sexual assault would eventually be known to the
inmate population. As a result, he requested SNY placement. Although initially double-celled
in administrative segregation on November 15, the inmate was subsequently relocated to a single
cell on November 17 following an investigation that determined his cellmate might be still gangaffiliated and a threat to him. The inmate was not placed in a suicide-resistant new intake cell
and committed suicide several hours later.
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and he did not have any medical
issues which were felt contributory to his death. According to the CDCR reviewer, “One of the
possible cumulative psychological triggers for the inmate suicide may have been his concern
over the “R” suffix and the potential consequences that could result from his gang or the prison
population as a whole. If discovered, this information may have put his safety in jeopardy.
Specifically, the inmate may have been fearful that the cellmate he was briefly housed with in
ASU, who was later identified to potentially not be serious about leaving his gang-affiliation,

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communicated the reasoning why the inmate was requested protective custody (potential “R”
suffix).”
The Suicide Report contained six recommendations for corrective action through a QIP:
1) In the MHPC MH Initial Assessment dated September 27, 2017, the
inconsistencies in the inmate’s prior reports of self-harm (accidental versus
suicide attempt) were not documented. Because of a lack of clarity, the rationale
for excluding the inmate from the MHSDS was not well formulated.
2) In performing the Suicide Risk Assessment/Self-Harm Evaluation (SRASHE)
on September 27, 2017, there are a number of documentation deficits. The
rationale for the estimation of acute and chronic suicide risk are not well
documented.
3) There was an 8-minute delay of activating 911. The delay most likely did not
change the patient outcome.
4) Per SOMS, the patient was transferred to ASU unit at 1156 on November 15,
2017. The ASU pre-placement screening was not performed until November 16,
2017 at 1002 per EHRS documentation. It was not clear if custody brought the
patient to a health care staff for pre-placement screening prior to ASU placement.
5) It was not clear how the two PTs notified the custody officers when they
visualized that the patient was hanging. The PT notes showed ‘We immediately
notified custody staffs and the COs responded right away, cut down the rope and
CPR initiated.’
6) A policy memorandum issued October 30, 2015 entitled, Revised
Administrative Segregation Unit Intake Cell Procedure states, ‘Under this revised
policy, when inmates are in their initial 72 hours of ASU placement and the cell
partner subsequently moves out of the cell, ASU staff shall immediately make
every effort to identify another compatible cell mate. If the inmate cannot be
double-celled with a compatible cell mate, ASU staff shall place the inmate in an
available ASU intake cell as soon as possible, but no later than eight hours after
the cell partner has been moved from the cell.’
The inmate was discovered hanging in his assigned cell approximately three hours
after the cell move had taken place. Although the inmate’s movement was
consistent with existing policy and procedures, this event prompts the review of
existing policy to check to determine if modifications are necessary.

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17)

Central California Women’s Facility (CCWF)

Inspection: December 7-8, 2017 (previous suicide prevention audit was on May 10-11, 2016).
CCWF housed approximately 2,952 inmates at the time of the on-site assessment.
Screening/Assessment: This reviewer observed a few new admissions during the intake
screening process in the RC on December 8. The nurse was observed to be asking all of the
questions and correctly entering the information into the EHRS. The door to the nurse’s office
was closed during the process, thus ensuring privacy and confidentiality.
The mental health diagnostic testing in the RC was observed on both December 7 and December
8. There were concerns raised during the mental health screening on December 7. In the
observed case (CCWF 1), the inmate had arrived at CCWF from the county jail on December 5,
2017. The nurse had timely completed the “Intake Health Screening-Female” form on December
5 in which the inmate had reported a prior history of mental illness, including Anxiety Disorder
and ADHD. She denied any current depression, auditory hallucinations, suicidal ideation, or any
prior history of suicidal behavior. A mental health referral was not generated. Two days later on
December 7, the inmate was seen by a mental health clinician for completion of the 31-item
mental health screening. The inmate answered affirmatively to the following questions: “Have
you ever made a suicide attempt?” (with the date of the attempt not solicited by the clinician),
“Have there ever been a few weeks when you’ve felt like you were useless, or sinful, or guilty?,”
“Have you ever been involuntarily committed for psychiatric problems?,” “Are you now or have
you ever taken any kind of medication or drugs for psychiatric or emotional problems?,” and
“Are you now or have you ever taken any antidepressants?” Based upon the affirmative
responses to the mental health screening, the inmate was referred for further mental health
evaluation.
This reviewer asked the clinician if they routinely reviewed both the intake health screening form
and any available discharge information from the county jail. The clinician responded by stating
that they and their colleagues responsible for the initial mental health screening waited until the
Mental Health Evaluation was completed before reviewing any previous records, including
county jail records. This reviewer’s concern with the clinician’s response was twofold: first, the
MHSDS Program Guide only required a Mental Health Evaluation to be completed if the inmate
answered affirmatively to any mental health questions on the 31-item mental health screening
form, and second, the Program Guide required the initial Mental Health Evaluation to be
completed within “18 calendar days,” although the process was historically completed earlier.
Under such a scenario, an inmate (not the one referenced above) who provided all “no”
responses to the mental health screening would not be referred for completion of a mental health
evaluation and would not have either the initial intake screening form or available county jail
records reviewed by a mental health clinician.
In the above case (CCWF 1), this reviewer’s subsequent examination of the available county jail
records indicated that the inmate had attempted suicide by drug overdose approximately ten days
earlier on November 24, 2017, with a note indicating that “she is depressed about being here but
does not want to die. Upset and emotional.” The county records also indicated she had been
prescribed an antidepressant. This reviewer’s examination of the EHRS indicated that the inmate
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had previously been incarcerated at CIW and placed on suicide precautions in the MHCB in
September 2017 for suicidal ideation. In addition to the November 2017 suicide attempt, the
inmate also had two suicide attempts in March 2016 by drug overdose. This information was
available to, but not reviewed by, the mental health clinician at CCWF during the RC diagnostic
testing on December 7, 2017. Based upon this reviewer’s findings, the inmate was subsequently
referred for completion of a SRASHE on December 8 which found a “high” chronic risk and
“moderate” acute risk for suicide. Following review of all available records, the clinician
completing that assessment found “more concerning from information gleaned was IP actually
was minimizing history more than originally” determined during the RC process.
This reviewer also observed the mental health diagnostic testing in the RC by another clinician
on December 8. During this observed screening, the clinician did review the available county
jail records.
In sum, it would appear that CCWF mental health leadership needs to provide direction to
clinicians assigned to the RC diagnostic testing area to ensure that they consistently review both
the most recent initial intake screening forms and any available county jail records prior to
and/or during completion of the 31-item mental health screening form. In addition, review of
Chapter 2 of the MHSDS Program Guide (“Reception Center Mental Health Assessment) found
that there was unclear language regarding requirements for review of health care information
from both county jails and prior CDCR confinements.
Finally, daily PT rounds in the administrative segregation unit (Building 504) were observed on
December 8. Building 504 contained GP inmates, STRH, administrative segregation EOP,
condemned unit, and alternative housing. The rounds were unremarkable, and the PT was
observed to be correctly entering Psych Tech Daily Rounds information into the EHRS for each
caseload inmate.
Housing: CCWF had a Skilled Nursing Facility (or CTC) with 12 designated MHCBs in eight
rooms. At the time of the assessment, one room was off-line for repair. Previously identified
hazards (i.e., square-shaped stainless-steel sinks and faucets with a horizontal slit known as
“anti-squirt slits”) had been replaced in the rooms that were now reasonably suicide-resistant.
The administrative segregation unit (Building 504) contained four retrofitted suicide-resistant
cells (128 thru 131) for inmates on new intake status. During this reviewer’s tour of the unit,
there were no new intake inmates housed in unsafe, non-new intake cells. Of note, three
previous special management cells were converted into regular administrative segregation cells
with standard bunks.
Finally, alternative housing cells to temporarily house inmates awaiting MHCB placement were
primarily found in Building 503 (RC housing), Building 504 (in the administrative segregation
section), and A-73 (a holding cell in the CTC). As noted above, the three special management
cells in Building 504 were no longer being utilized for either special management or alternative
housing, correcting a previous problem. All inmates in alternative housing were observed on a
1:1 basis and furnished bunks. Alternative housing continued to be used extensively at CCWF,
with more than three inmates on the status each day. From August 25 through December 5,
2017, there were 266 inmates placed in alternative housing, with only 43 percent discharged
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within 24 hours. Of the 57 percent of inmates who remained in alternative housing for more than
24 hours, a sizable number (i.e., 91 or approximately 34 percent of all inmates) were housed for
4.4 days or over 105 hours. The overall length of stay in alternative housing for all 266 inmates
was 51 hours.
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCB. In addition, patients not on suicide observation status were being observed at 15-minute
intervals. This reviewer subsequently verified the accuracy of observation rounds by reviewing
the EHRS charts of four patients on Suicide Precaution status in the MHCB unit during ninehour periods from 12:00 a.m. through 8:59 a.m. on several sample days (November 16 for
CCWF 2, December 1 for CCWF 3, December 6 for CCWF 4, and November 6 for CCWF 5).
The chart review found a few observation checks (between one and four per patient) that were in
excess of required 15-minute intervals for all four patients, with the longest gap between checks
being 38 minutes for CCWF 5. Violations in the four cases were by multiple nursing staff.
A previous problem with clinicians not making daily determinations as to possessions and
privileges afforded to MHCB patients had been corrected, and visits and telephone privileges
were being approved based upon clinical determination. With one exception, out-of-room
privileges, including yard, were being afforded to MHCB patients. The exception was patients
on maximum-security or administrative segregation statuses did not have access to the program
room in the unit. This reviewer was informed that there was a pending work order to install a
“Restart Chair” in the program room. No timetable for the installation was provided.
This reviewer observed several IDTT meetings for MHCB patients on both December 7 and 8.
In the first case (CCWF 4) on December 7, the patient had been in the MHCB for eight days
after being confined in alternative housing for an additional eight days. She was at 3CMS level
of care and had an extensive history of SI and SIB. The patient had a diagnosis of Bipolar
Disorder and had previously been treated at Patton State Hospital. She had denied any suicidal
ideation and had been medication compliant since her MHCB admission. The IDTT was
recommending the patient’s discharge to EOP and she was concerned about how the new level of
care would affect her upcoming parole board consideration. There was adequate discussion
regarding safety planning, including utilizing the patient’s coping skills of reading, journaling
and deep breathing exercises. Finally, for purposes of transition, both the patient’s current
3CMS clinician and newly assigned EOP clinician were at the IDTT meeting. This was an
excellent practice.
This reviewer subsequently examined the safety plan section of patient’s discharging SRASHE.
Unfortunately, narrative in the safety plan was not consistent with the discussion of safety
planning during the IDTT. However, review of the first day of the patient’s five-day follow-up
progress note was consistent with the IDTT discussion and stated the following: “IP seen for Day
1 of 5-day follow-up and 30-minute custody checks were continued as patient continues to
endorse symptoms of anxiety. IP denied current SI or HI. Safety plan discussed the following: 1)
IP will remain on 30-minute checks at this time; 2) IP will use coping skills including taking a
shower, reading, and practice relaxation skills including deep breathing and shoulder shrugs to
help cope with anxiety; 3) MHPC will provide IP with a journal to use in order to write her
stories; and 4) IP will inform staff if she experiences SI.”
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The IDTT meeting observed on December 8 included different team participants from the
previous day. The patient (CCWF 6) had been in the MHCB for 11 days after being confined in
alternative housing for an additional seven days. She was at the 3CMS level of care and had a
minor history of suicide ideation. Diagnosed with Bipolar Disorder, she denied any suicidal
ideation and had been medication compliant since her MHCB admission. The patient had a
history of volatile behavior and was observed wearing a spit mask during the meeting due to a
previous incident of spitting on an officer during escort to administrative segregation. There was
no discussion during the IDTT meeting regarding safety planning other than the lead clinician
reemphasizing medication compliance to the patient. The patient was discharged to EOP level of
care. This reviewer subsequently examined the safety plan section of patient’s discharging
SRASHE. The safety plan stated: “PC will work with IP to increase insight into medication
compliance and how it directly affects functioning in the hopes of decreasing impulsivity. IP
will be provided with education on thought records (increased awareness), different forms of
relaxation, and other self-soothing techniques to employ and urges to self-harm or suicidal
ideation emerge. IP will verbalize an understanding of how to contact MH staff in an
emergency.” Of concern was the fact that none of the above described safety plan was discussed
during this patient’s IDTT meeting on December 8.
Finally, a review of Guard One data for a recent 24-hour period within Building 504 found 100percent compliance with the required checks not exceeding 35 minutes. It should be noted,
however, that this level of compliance was not an accurate reflection of the overall level of
observation of inmates housed in Building 504. As detailed in the previous assessments,
Building 504 at CCWF was unique in that it housed the condemned unit containing 22 single
cells. Seventeen of the cells were located within an enclosed program area on the first floor of
the unit, with five cells located outside the enclosed program area. According to CCWF custody
officials and staff, because condemned unit inmates had regular access to the enclosed program
area outside their cells, but within the chain-link fenced area, Guard One rounds were not
conducted except during the First Watch. A May 9, 2014 directive from the Director of the
Division of Adult Institutions entitled, “Security/Welfare Check Procedure Utilizing the Guard
One System to Supersede Administrative Segregation Unit Welfare Check and Security/Custody
Rounds in Specialized Housing Procedures” supported such a practice by citing the “unique
design and programs” of the enclosed condemned unit. In addition, five of the condemned unit
cells remained outside of the enclosed program area and adjacent to other administrative
segregation unit cells that were subject to Guard One surveillance. There continued to be no
practical reasons why these five condemned unit cells should not be subject to Guard One
surveillance.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS for the period of August through
November 2017. This reviewer’s sample EHRS review of 40 emergency mental health referrals
for suicidal ideation/behavior revealed that clinical staff completed the required SRASHEs in 93
percent (37 of 40) of the cases, a significant improvement from the previous assessment in which
the compliance rate was only 82 percent.

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In addition, this reviewer examined a sample of ten SRASHEs from patients released from a
MHCB between August and November 2017. Most of the safety plan sections of the SRASHEs
did not adequately address specific strategies to reduce suicidal ideation. One case (CCWF 7)
symbolic of the problem contained the following safety plan: “Discharge to 3CMS LOC with 5day follow-up. Discuss coping skills for substance abuse, pending court case, family separation,
and missing her children.”
Ironically, in a case discussed above (CCWF 6), although the safety plan contained in the
discharging SRASHE on December 8 was viewed to be inadequate (as well as never discussed
with the patient during the IDTT), when the same patient was previously discharged from the
MHCB on November 6, 2017, the safety plan was very reasonable:
IP to work with RC 3CMS PC to continue practicing self-soothing skills, physical
exercise - walking; deep belly breathing and thinking future positive-oriented
thoughts, taking meds, not getting any more RVRs, thinking about paroling on
2/08/18, and starting SSI application process. To develop new skills to continue
to stabilize mood, reduce hypomanic behavior.
IP to work with RC MHPP by continuing her psych meds and being open about
side effects and other issues as opposed to stop taking them which she did prior to
MHCB admit.
IP to work with CC1 on endorsement process in A yard and to consider resources
- programs that can continue to stabilize her.
MHCB PC reviewed safety plan with IP and discussed triggers to recent
decompensation, including anger over conflicts with other IMs that have
contributed to her acting-out by not taking meds, faulty thinking of ‘trying to get
back at others,’ and not thinking of consequences. IP to implement above stated
self-soothing skills when this happens.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 315 cases of patients discharged from a
MHCB or alternative housing placement that remained at CCWF and not transferred to the
administrative segregation unit (where observation at 30-minute intervals was required) from
June through November 2017. The review found that 93 percent had Page One of the
“Discharge Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental
health clinicians, with the majority (60 percent) of the custody checks recommended for only 24

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hours by clinicians. In addition, 97 percent of the “custody check” forms (Page Two) were
completed correctly by correctional staff at 30-minute intervals.
Intervention: All toured housing units contained an emergency response bag that included a
micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (August through
October 2017) found that quorums were not achieved in any of the meetings, ironically only
because the senior PT or designee were not invited to participate. The meetings were
consistently 90 minutes in length, but otherwise unremarkable.
Training: According to training records, approximately 91 percent of custody staff and 100
percent of nursing staff were currently certified in CPR. In addition, 93 percent of custody, 95
percent of medical, and 96 percent of mental health staff had received annual suicide prevention
block training during 2016. Finally, as of November 2017, only 77 percent of mental health
clinicians had completed the SRE mentoring program, 96 percent had received the seven-hour
SRE training, and 91 percent had completed safety plan training.
Recent Suicides: CCWF experienced one inmate suicide during the reporting period. In that
case (CCWF 8), the inmate was found hanging from the locker by a sheet in her administrative
segregation cell during the late evening of October 28, 2017. The inmate was a transgender
identified individual (biologically female and identifying as male) who entered CDCR for a
second term on June 24, 2013 to serve a 13-year sentence for assault with a deadly weapon. (For
purposes of this review, the inmate will be identified by their preferred pronoun.) He was
transferred between CCWF and CIW various times during the second term, and most recently
transferred back to CCWF on March 15, 2017. The inmate had a significant number of RVRs,
approximately 60 during his confinement, including four that occurred in the last five months of
his life and remained pending at the time of the suicide. These incidents included assaulting a
nurse, destruction of state property, covering the cell window with cardboard, and refusing a
housing transfer. He had approximately 21 administrative segregation placements as result of
these RVRs. The inmate was not known to be gang-affiliated and was unmarried with a 14-yearold son. Family support was demonstrated by letter correspondence and occasional visits.
According to available records, the inmate and four sisters were raised by their parents, as well
as by a grandmother for a period of time, in an unstable environment that included domestic
violence and physical abuse by a stepfather. Both parents had substance abuse problems, and
several family members had been involved in the criminal justice system. The inmate was
sexually molested by his mother’s friend at age 5, as well as by an uncle at age 8. The
molestation continued until he was 15-years-old. As a result, he did poorly in school and began
abusing illegal drugs. As a teenager, the inmate was rejected by his parents for his sexual
orientation. His involvement in the criminal justice system began at age 18 when a series of
robberies were committed under the influence of crack cocaine and methamphetamine.
The inmate had a significant history of mental illness, as well as self-harming behaviors that
included cutting himself and head-banging beginning at age 8 and continuing into adulthood. He
also had a long history of suicide attempts which started at age 8 with a drug overdose and
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continued with other incidents including deep arm lacerations and two attempted suicides by
hanging at age 18. The inmate reported three hospitalizations in the community for suicide
attempts and psychosis. Upon entry into CDCR for the second term, the inmate was placed at
3CMS level of care and provided diagnoses of Adjustment Disorder with Anxiety and
Depression, Bipolar Disorder, Antisocial Personality Disorder, Post-Traumatic Stress Disorder,
Gender Dysphoria, and Borderline Personality Disorder.
In addition to the inmate’s history of suicidal behavior in the community, he also attempted
suicide on two occasions at CCWF during the first CDCR term. The inmate had approximately
11 MHCB placements beginning in February 2016 and ending in September 2017, with an initial
placement in alternative housing for suicidal ideation and a subsequent MHCB rescission. As of
September 22, 2017, he was assessed as having a ‘moderate” chronic risk and “low” acute risk
for suicide. The inmate was elevated to EOP level of care following the ninth MHCB placement
due to increases in head-banging, depressive symptoms, hopelessness, tendency to isolate, and a
decrease in baseline functioning. He was also placed in the PIP from July through September
2016. During the last year, the inmate rarely participated in group treatment, attending only ten
of 78 treatment modules offered.
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and although experiencing several
medical issues, they were not thought to be contributory to the death. However, the reviewer
opined that the inmate’s suicide was probably precipitated by both accumulating RVRs and the
“toxic” long-term romantic relationship he had with another inmate in the administrative
segregation unit which culminated in an argument shortly before the suicide on October 28,
2017.
The Suicide Report contained three recommendations for corrective action through a QIP:
1) The September 22, 2017 SRE was found to be deficient during the course of
this review and by an audit performed at CCWF.
2) The primary officer’s CDCR 837 states they visually observed cell 117 being
covered up, blocking the view of staff. The primary officer ordered the inmate to
take down the window covering with negative results as the inmate verbally stated
‘no.’ The officer reported leaving the immediate area of cell 117 to complete
Guard One checks and returned 20 minutes later in an attempt to reestablish
communication with the inmate.
3) During autopsy, 23 pills were found in the inmate’s vaginal cavity.
18)

San Quentin State Prison (SQ)

Inspection: January 2-3, 2018 (previous suicide prevention audit was on September 29-30,
2016). SQ housed approximately 3,920 inmates at the time of the on-site assessment.

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Screening/Assessment: This reviewer observed several new admissions during the medical
intake screening process in the RC on January 3. The nurse was observed to be asking all of the
questions and correctly entering the information into the EHRS. The door to the nurse’s office
was closed during the process, thus ensuring privacy and confidentiality. This reviewer also
observed the mental health diagnostic testing in the RC for two newly-admitted inmates on
January 3. Both screenings were thorough.
Daily PT rounds in administrative segregation (Carson Unit) were observed on January 2. The
rounds were unremarkable, and the PT was observed to be correctly entering information from
the Psych Tech Daily Rounds Form into the EHRS for all caseload inmates.
Housing: SQ had 40 PIP rooms for condemned inmates. All non-condemned SQ patients
requiring a crisis level of care were referred to outside MHCBs. All PIP rooms were suicideresistant and did not contain any obvious protrusions which could be used in a suicide attempt by
hanging.
The administrative segregation (Carson) unit contained approximately 30 new intake cells on the
first (1C8-1C22) and second (2C1-2C15) tiers. All the new intake cells were retrofitted to be
suicide-resistant. Due to a low census, many of the new intake cells were empty and all new
intake inmates were observed to be in new intake cells.
Finally, alternative housing to temporarily house inmates identified as suicidal and awaiting
MHCB placement was found in either the ten licensed medical beds in the CTC, TTA cells, or
various large holding cells scattered throughout the CTC building. Alternative housing was used
on a daily basis, and inmates were all furnished beds and observed on a 1:1 basis. From April 1
through December 31, 2017, there were approximately 159 inmates placed in alternative housing
and 96 percent were released within 24 hours. The overall length of stay in alternative housing
for all 159 inmates was 16 hours.
Observation: All patients in the PIP at MHCB level of care were on either Suicide Precaution
or Suicide Watch status. All other PIP patients were under ICF level of care and observed at 60minute intervals. This reviewer subsequently verified the accuracy of observation rounds by
reviewing the EHRS charts of three patients (SQ 1, SQ 2, and SQ 3) on Suicide Precaution status
in the PIP during a nine-hour period from 12:00 a.m. through 8:59 a.m. on January 2, 2018. The
chart review found numerous observation checks (nine per patient) that were in excess of the
required 15-minute intervals, with the longest gap between checks being 67 minutes in one case
(SQ 1). The following case (SQ 2) exemplifies the significance of the problem: There were nine
violations of 25-, 21-, 20-, 19-, 18-, 18-, 20-, 17-, and 32-minute gaps between the required 15minute intervals. Violations in the three cases were committed by multiple nursing staff.
This reviewer observed four IDTT meetings on January 2: two patients at MHCB level of care
and two patients at ICF level of care. All IDTT meetings were well represented by mental
health, medical and custody staff. Of note, the IDTT meetings for MHCB patients included
representation of two outpatient psychologists from the Condemned Unit who were designated to
the CTC for the sole purpose of participating in the IDTT for non-PIP patients. During the IDTT
meeting for MHCB patients, this reviewer observed that the two out-patient psychologists
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dominated the sessions, with very little input solicited from other team members; whereas during
the IDTT meetings for PIP patients, there was much more interaction amongst all team members.
Despite this concern, this reviewer observed good safety plan discussion during the IDTT
meetings for MHCB patients.
Finally, a review of Guard One data for a recent 24-hour period found a combined 93-percent
compliance with required checks that did not exceed 35-minute intervals in the administrative
segregation (Carson) and two condemned unit sections.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS for the period of July through
October 2017. In addition, various TTA logs were also reviewed for the period of July through
December 2017. This reviewer’s sample EHRS review of 45 emergency mental health referrals
for suicidal ideation/behavior revealed that clinical staff completed the required SRASHEs in 96
percent (43 of 45) of the cases. This finding was a significant improvement from the previous
assessment in which only 88 percent of the SRASHEs were completed.
In addition, this reviewer examined a sample of eight SRASHEs from patients released from the
MHCB level of care at the PIP or alternative housing between July and December 2017. In two
cases (25 percent), the discharging assessments could not be found in the EHRS. Of the
remaining six cases, the quality of the safety plans contained within the discharging SRASHEs
ranged from adequate to problematic. Most of the safety plans were problematic, and simply
contained recommendations to outpatient clinicians to assist the patients with development of
safety planning. For example, in one case (SQ 1) that this reviewer observed during the IDTT on
January 2 and found adequate discussion of safety planning, the narrative for the patient’s safety
plan contained within the discharging SRE dated January 3, 2017 stated: “Over the next 30 days
(in outpatient), the IP will work with his PC 1:1 on a weekly basis to identify three triggers of his
(substance) use and two replacement behaviors. He will also be enrolled in substance recovery
group. Given the IP is currently being recommended for discharge from the MHCB, psychoeducation centering on methods of contacting mental health should the need arise; he was
receptive and indicated that he understood.” In another case (SQ 4), the clinician utilized the
same safety plan narrative for multiple patients: “The IP’s Tx team will work with the IP to
identify at least one coping skill to help him mitigate the experience of psychiatric distress over
the next seven days. Furthermore, the IP will work with his treatment team to identify two areas
of this treatment plan that he can more fully engage in MH program; this will be done in an
effort to reduce barriers to progress.”
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.

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This reviewer was presented with documentation of 48 cases of patients discharged from a
MHCB, alternative housing placement, or PIP and returned to mainline SQ and not transferred to
administrative segregation or the condemned unit (where observation at 30-minute intervals was
required) between June and December 2017. The review found that 89 percent had Page One of
the “Discharge Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental
health clinicians, with approximately 74 percent of the custody checks recommended for the
maximum period of 72 hours. In addition, only 74 percent of the “custody check” forms (Page
Two) were completed correctly by correctional staff at 30-minute intervals. Of note, although
these compliance levels were in need of improvement, they were substantially higher than this
reviewer’s previous assessment which found various problematic practices, including the fact
that many “Discharge Custody Check Sheet” (CDCR MH-7497) forms could not be located and
observations for all remaining cases were not occurring at the required 30-minute intervals.
Intervention: All housing units toured by this reviewer contained an emergency response bag
that included a micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (August through
November 2017) found that quorums were not achieved in any of the meetings. The meeting
minutes were otherwise unremarkable.
Training: According to training records, 99 percent of custody staff and 100 percent of nursing
staff were currently certified in CPR. In addition, 99 percent of custody staff, 94 percent of
medical staff, and 100 percent of mental health staff received annual suicide prevention block
training during 2016. Finally, as of December 2017, 96 percent of mental health clinicians had
completed both the SRE mentoring program and seven-hour SRE training, and 97 percent had
completed safety plan training.
Recent Suicides: SQ experienced two inmate suicides during the review period. In the first
case (SQ 5), the inmate was found hanging from the bookshelf by a sheet in his administrative
segregation unit cell during the evening of January 27, 2017. He entered the CDCR system
through SQ for the third time on November 16, 2016 to serve a six-year sentence for assault with
force likely to produce great bodily harm. The inmate did not incur any RVRs during his
confinement and was not known to be gang-affiliated. He was twice divorced and had three
young children. The inmate had limited family support through letter correspondence with his
grandmother, but no visits or telephone calls during his approximate 73-day confinement.
According to available records, the inmate was primarily raised by his grandparents because his
biological parents suffered from substance abuse. He self-reported being emotionally and
physically abused by his mother, as well as robbed at gun point and sexually assaulted by a
stranger at age 16. The inmate began using illegal drugs at age 17 and was placed in various
drug treatment programs pursuant to court orders. His previous CDCR terms covered 2001
through 2004, as well as 2014 through 2015.
During the inmate’s prior CDCR terms, he did not self-report any mental health problems and
was not placed in the MHSDS. However, when provided initial mental health screening through
the RC on November 16, 2016, he reported over 20 previous suicide attempts, as well as a
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significant mental health history that included five psychiatric hospitalizations. He also reported
a diagnosis of ADHD as a child. During a mental health evaluation on November 30, the
inmate’s previously reported 20 suicide attempts was revised to three prior suicide attempts,
including exsanguination and hanging while confined in a county jail during 2013, as well as an
attempted hanging in a county jail in 2014. (Although completed, an SRE that noted both chronic
and acute risk for suicide as “moderate,” was not entered into the inmate’s medical chart.) The
inmate also endorsed a number of symptoms, including poor sleep and appetite, paranoia,
hallucinations, and racing thoughts. Based upon the fact that he did not disclose such
information during prior CDCR confinements, the inmate was initially viewed as an unreliable
historian. Nonetheless, on November 30, 2016, he was placed in the MHSDS at the 3CMS level
of care with a diagnosis of Psychotic Disorder NOS, as well as prescribed psychotropic
medication.
On January 21, 2017, the inmate was placed in the administrative segregation unit after being
assaulted by three other inmates. When interviewed, he admitted to owing a drug-related debt
but did not seek SNY placement. Several days later on January 25, the inmate was seen by his
psychiatrist for a follow-up assessment, as well as by a newly assigned PC. He reported both
current auditory and visual hallucinations and rated his level of depression as eight out of ten.
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and although the inmate had
several medical issues, including chronic back pain, these issues were not thought to be
contributory to his suicide. However, the reviewer opined that increasing complaints of auditory
hallucinations, anxiety regarding loss of custody of one of his children, safety concerns related to
the recent assault from three other inmates and being taunted by other administrative segregation
inmates to commit suicide a few days prior to his death, were likely precipitants to his suicide.
The Suicide Report contained 11 recommendations for corrective action through a QIP.
1) On November 30, 2016, a Suicide Risk Evaluation was completed and sent to a
reviewing clinician. The SRE was reviewed and returned to the clinician with
comments and requests for edits. However, the completing clinician did not
resubmit a revised SRE. Therefore, no SRE was available in the electronic health
record until two days prior to the inmate’s death.
2) On January 25, 2017, an IDTT was held without the inmate being present. He
was seen after the IDTT was held, with a treatment plan completed after the IDTT
had already occurred. This suggests that the IDTT meeting was held with little
information known about him and without his input either in person or via
evaluations from members of the IDTT. The reason for his refusal to participate
in the IDTT was not reported on a CDCR 7230-MH as required by the MHSDS
Program Guide, 2009 revision. Finally, it is unclear if the IDTT psychiatrist was
aware of the concerns about the inmate’s depression and psychotic agitation.
These concerns were documented after the IDTT team meeting occurred. The
psychiatrist met with him on January 25, 2017 (after the IDTT) but did not initiate
treatment for depression or psychosis prior to the inmate’s death.
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3) On January 25, 2017 the inmate reported to his clinician (after the IDTT
meeting) that he had been distressed due to child custody hearings and loss of his
custodial/parental rights at the end of court hearings. These hearings occurred
between February 2016 and April 2016. However, the protective factor ‘children
at home’ was endorsed and ‘has three young children in the community’ was
included in the risk formulation of the SRE. The same SRE appears to
underestimate both chronic and acute risk, particularly as several imminent risk
factors were present (substance abuse, anxiety, anger, recklessness, and mood
changes), perhaps as a strength of protective factors was overestimated in the
case.
4) On January 25, 2017, a mental health treatment plan was completed by IDTT
in ASU. The treatment plan lists imminent risk factors and reports on the
inmate’s history of suicide attempts yet identifies only one problem for the
treatment plan: psychotic symptoms. Psychotic symptoms are noted to cause him
to engage in self-harm behaviors ‘due to distress from AH.’ However, the shortterm goals listed for the inmate focus on decreasing depression.
5) On January 25, 2017, the inmate reported to a mental health clinician that he
was being taunted and encouraged to harm himself by other inmates. There was
no mental health documentation found regarding the inmate report and no
documentation that report was shared with custody officers or psychiatric
technicians in ASU, such as during morning huddles.
6) On January 26, 2017, a clinician observed the inmate in ICC and/or
interviewed him after ICC. The note written by the clinician was inadequate
regarding this clinical contact. The entire note states, ‘ICC hearing on
01/26/2017. Patient reports mood as ‘good.’ He was smiling. Denied HI/SI.’
7) Per Departmental memorandum entitled, ‘Multi-Powered Radio Loaner
Program in Administrative Segregation,’ dated January 22, 2014, upon
completion of the administrative review, ASU inmates shall be given the
opportunity to be issued a radio and ear-buds. Based on the documentation
provided by the institution, SQ failed to adhere to this policy.
8-11) Four nursing concerns were identified. The nursing concerns were Narcan
was administered twice without a physician’s order, the SQ LOP for Loss of
Consciousness was out of compliance, a PT incorrectly noted on the PT Daily
Rounds form that the inmate was medication compliant on January 22, 2017, and
the LVN did not complete the medication management referral after the inmate
had refused his ADHD medication for three days.
In the second case (SQ 6), the inmate jumped from the upper tier of his RC housing unit during
the early evening of October 7, 2017. (Of note, the death was originally listed as suspicious and
a possible homicide, but subsequently changed to a suicide.) He entered the CDCR system
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through SQ on July 19, 2017 to serve a 25-year-to-life sentence for first-degree murder. The
inmate did not have any RVRs and had no gang affiliation. He was married and had two
children. Although still on RC status and not yet eligible for visits and telephone calls at the
time of his death, the inmate had family support from his wife, children, and mother.
According to available records, the inmate was raised by both parents in Mexico and was
physically abused by his alcoholic father. Because his family was poor, the inmate had dropped
out of school and obtained various part-time jobs. As a teenager, he subsequently immigrated to
the United States with a cousin and found various jobs. However, beginning at age 19, the
inmate began abusing alcohol and cocaine which led to his involvement in the criminal justice
system.
The inmate did not have any mental health treatment in the community but was treated for both
depression and anxiety in the county jail following a suicide attempt by cutting in December
2016. Upon arrival to the SQ-RC, the inmate screened positive for mental health symptoms
including auditory hallucinations, depression, and the prior suicide attempt. He denied any
current suicidal ideation. The inmate was subsequently placed at the 3CMS level of care with
diagnoses of Adjustment Disorder and Unspecified Anxiety and Depressive Disorders. Although
the inmate was seen by two different psychiatrists on both July 19 and August 7, 2017, there
were no psychiatric notes or assessments entered into the EHRS. Two months later on October
6, 2017 and two days before the suicide, he met with a psychiatrist who wrote a note that stated,
in part, that the inmate “appeared alert and oriented with some signs of anxiety, no abnormal
associations or pressured speech. He reported having constant auditory hallucinations…. Telling
him his family had been killed and that he would be killed, though he showed no signs of
responses to internal stimuli. His thought process appeared linear and goal directed.”
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide, and although the inmate had
several medical issues, they were not thought to be contributory to his death. According to the
reviewer, “This review did not reach a clear explanation for the inmate suicide. Concerns about
his safety, as he voiced in the weeks before his death, combined with the silence of inmates
interviewed during this process and aspects of his fall from the tier raise questions about the
circumstances surrounding his death and suggest the possibility he did not commit suicide.”
The Suicide Report contained four recommendations for corrective action through a QIP:
1) On the day of his arrival at SQ, the inmate received an Initial Psychiatric Intake
Assessment. No documentation of the assessment was found in his records and
the psychiatrist had left the facility by the time the on-site review of the inmate
suicide.
A second psychiatric assessment was provided to the inmate on August 7, 2017.
No documentation was found in his records describing the content of that contact.
During the on-site death review, the psychiatrist produced copious handwritten
notes detailing an extensive assessment.

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2) The result of a Mental Health Screening interview found the inmate positive
for suicide risk, but the urgent mental health consult was conducted two days after
the screening, not within Program Guide timelines, which specify a 24-hour limit.
No orders for the urgent consult were found in the EHRS.
3) The patient sustained a skull fracture with brain matter exposed and loss of
blood from that site. No documentation from the emergency response indicated
that bleeding control was initiated even after the patient regained a pulse or that
the site was dressed with a sterile dressing.
4) Emergency Medical Services (EMS) was activated at 1925 hours according to
nursing documentation. The ambulance did not arrive to the TTA until 1955
hours, 30 minutes from activation. Standard response time is less than 10 minutes.
19)

California Medical Facility (CMF)

Inspection: January 4-5, 2018 (previous suicide prevention audit was on May 24-25, 2016).
CMF housed approximately 2,545 inmates at the time of the on-site assessment.
Screening/Assessment: This reviewer observed a few new admissions during the intake
screening process in the R&R unit on January 4, 2018. The nurse was observed to be asking all
of the questions and correctly entering the information into the EHRS. The door to the nurse’s
office was closed during the process, thus ensuring privacy and confidentiality.
In addition, this reviewer had the opportunity to observe required daily rounds by a PT assigned
to one (I-3) of the three administrative segregation units on January 5. The rounds were
unremarkable, and the PT was observed to be correctly entering the Psych Tech Daily Rounds
information into the EHRS for each caseload inmate.
Housing: CMF had 49 MHCBs located on two wings of the CTC. All rooms continued to be
suicide-resistant and furnished with suicide-resistant beds. This reviewer inspected the three
administrative segregation units (I-3, M-3, and Willis) and found that seven new intake cells had
been retrofitted to be suicide-resistant. The new intake cells in both the I-3 Unit and Willis Units
were either at or below capacity on January 5, however, inspection of M-3 Unit found that both
new intake cells were full and one new intake inmate was housed in a non-new intake cell. A
correctional supervisor informed this reviewer that the unit averaged three new intake inmates on
a regular basis, and additional retrofitted new intake cells were needed. There was no indication
that a work order had been requested for any additional new intake cells. The issue of new
intake inmates placed in unsafe, non-new intake cells was previously raised during the 2014 and
2016 reviews and continued to be problematic.
Finally, alternative housing cells to temporarily house inmates identified as suicidal and
awaiting MHCB placement were primarily found in MHCB observation cells. Alternative
housing was utilized on a daily basis, and inmates were all furnished beds and observed on a 1:1
basis. From September 26 through December 22, 2017, there were 90 inmates placed in
alternative housing, and all were discharged in approximately 24 hours. The vast majority (88
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percent) were transferred to a MHCB. The overall length of stay in alternative housing for these
90 inmates was 18 hours.
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCB unit. In addition, patients not on suicide observation status were observed at 30-minute
intervals by nursing staff. This reviewer subsequently verified the accuracy of observation
rounds by reviewing the EHRS charts of three patients (CMF 1, CMF 2, and CMF 3) on Suicide
Precaution status in the CTC during the nine-hour period from 12:00 a.m. through 8:59 p.m. on
January 3, 2018 (for CMF 1 and CMF 2) and January 5, 2018 (for CMF 3). The chart review
found numerous observation checks (i.e., between 12 and 15 per patient) that were in excess of
required 15-minute intervals, with the longest gap between checks being 49 minutes in one case
(CMF 2). The following case (CMF 3) exemplifies the significance of the problem: There were
13 violations of 19-, 20-, 31-, 22-, 20-, 21-, 21-, 43-, 29-, 16-, 18-, 18-, and 19-minute gaps
between the required 15-minute intervals. Violations in these three cases were committed by
multiple nursing staff. This reviewer was subsequently informed that a primary reason for this
problem could be that one nursing aide was responsible for the observation of 20 to 25 patients.
With one exception, this reviewer observed that MHCB patients were clothed and received
possessions and privileges consistent with their observation level. The exception was a patient
(CMF 4) observed during the IDTT meeting on January 4 to be on “full-issue” clothing but had
not received any privileges apparently due to a suicidal gesture two weeks earlier in which he
briefly climbed on top of his sink. With the exception of the RT, all other IDTT members were
unaware that the patient did not have any out-of-cell privileges. In addition, a random review of
documentation pertaining to privileges found that, although most MHCB patients assigned to the
B-Wing were routinely receiving yard and other out-of-cell privileges, there was little
documentation that patients assigned to the A-Wing were routinely receiving yard privileges
during the previous two weeks.
This reviewer observed seven IDTT meetings in the MHCB unit on January 4-5. Although the
treatment teams were well represented by mental health, medical, and custody staff, discussion
about safety planning for patients was very problematic. In one case (CMF 3), the patient had
been admitted into the MHCB a few days earlier on January 2 for self-injurious behavior.
Although denying any current suicidal ideation during the IDTT on Friday, January 5, there was
no discussion regarding safety planning and the PC simply informed the patient that the team
“will try to discharge you on Monday.” In another case (CMF 5), the patient also had been
admitted into the MHCB for suicidal ideation on January 2 and there was no discussion
regarding safety planning either before or after the patient told the treatment team that he would
not alert staff if he had “intent or a plan” to commit suicide.
Finally, a review of Guard One data for a recent 24-hour period in the three administrative
segregation units found a combined 98-percent compliance rate with required checks that did not
exceed 35-minute intervals.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS for the three-month period of
September through December 2017. In addition, the TTA log for the same period was reviewed.
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This reviewer’s sample EHRS review of 48 emergency referrals for suicidal ideation/behavior
revealed that clinical staff completed the required SRASHEs in only 79 percent (38 of 48) of the
cases. A similar low compliance rate for SRE completion was found during the preceding
assessment.
This reviewer also examined a sample of ten SRASHEs from patients released from a MHCB
during October and December 2017. Most of the assessments were problematic with regard to
adequate safety planning. For example, the safety plan section of the discharging SRASHE in
one case (CMF 6) of a patient admitted to the MHCB for suicidal ideation and self-injurious
behavior stated “Pt will return to EOP LOC and program. He will attend his 1:1 clinical
sessions, 10 groups assigned to him, and engage in tx w/his designated psychiatrist. Pt will let
his EOP team know when he is distressed and/or hearing AH or VH immediately so that he may
be provided w/reminders about coping skills and ways to decrease his perpetual disturbances.”
In another case (CMF 7), the patient had a significant history of suicidal and self-injurious
behavior, including eight previous suicide attempts and numerous self-injurious behaviors by
cutting. The safety plan section of the discharging SRASHE simply stated: “I suggest that his
long-term primary clinician develop a treatment objective and plan to replace his behavior of
superficial cutting to relieve anxiety with an adaptive behavior to relieve anxiety.”
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 98 cases of patients discharged from a
MHCB or alternative housing placement that remained at CMF and were not transferred to
administrative segregation (where observation at 30-minute intervals was required) from June 30
through December 30, 2017. The review found that only 26 percent had Page One of the
“Discharge Custody Check Sheet” (CDCR MH-7497) forms completed correctly by mental
health clinicians, with approximately 69 percent of the custody checks recommended for only 24
hours. In addition, only 67 percent of the “custody check” forms (Page Two) were completed
correctly by correctional staff at 30-minute intervals, with problems related to gaps in
documentation. Similar low compliance rates were found during the previous assessment.
Intervention: All housing units toured by this reviewer contained an emergency response bag
that included a micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (October through
December 2017) found that a quorum was only achieved in one month (November). The
meeting minutes were otherwise unremarkable.
Training: According to training records, 97 percent of custody staff and 100 percent of nursing
staff were currently certified in CPR. In addition, approximately 96 percent of custody staff, 52
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percent of medical staff, and 80 percent of mental health staff received annual suicide prevention
block training during 2017. Finally, as of December 2017, only 74 percent of mental health
clinicians had completed the SRE mentoring program, only 51 percent had received the sevenhour SRE training, and 91 percent had completed safety plan training. Similar low compliance
rates for suicide prevention training by medical and mental health staff were found during the
preceding assessment.
Recent Suicides: CMF experienced two suicides during the review period. In the first case
(CMF 8), the inmate was found to have exsanguinated himself during the morning of March 21,
2017 in his GP cell. He had also attempted to hang himself from a ventilation grate by a sheet.
The inmate entered the CDCR system on January 21, 2015 to serve a 22-year sentence for
carjacking, burglary, and assault. He was transferred to CMF a few months later on March 19,
2015. The inmate incurred four RVRs during his confinement, the most recent of which
occurred on December 28, 2016 for possession of morphine. He was not known to be gangaffiliated. The inmate had regular family support from his mother and sister, with several visits
and over 50 telephone calls with family members over a three-month period leading to his death.
The inmate was born in Mexico and raised by his mother until age 12 when he immigrated to the
United States to live with his father. He began to experience substance abuse problem shortly
thereafter. The inmate dropped out of school and briefly worked in construction with his father.
He was arrested several times for offenses relating to his substance abuse. The inmate did not
report any history of mental illness in the community, although he did report at least two prior
suicide attempts by hanging at age 17 or 18 that occurred under the influence of
methamphetamine and were triggered by the breakup with his girlfriend. At the time of his
death, the inmate was single and did not have any children.
Upon arrival into CDCR, the inmate screened positive for mental health issues based upon a selfreport of taking psychotropic medication for depression while confined in the county jail, as well
as a history of suicide attempts. He also complained of experiencing hallucinations when taking
methamphetamine. He was placed at the 3CMS level of care with diagnoses of Major
Depressive Disorder, Psychotic Disorder NOS, and Polysubstance Dependence. The inmate was
a participant in the MHSDS and mostly compliant with medication. He did not report any
suicidal ideation or intent during his CDCR confinement and was rated at “moderate” chronic
risk (due to his prior suicide attempts) and “low” acute risk for suicide on his only SRE
completed in January 2015.
The inmate experienced several medical problems, the most important of which was chronic pain
and headaches related to a gunshot wound to his skull that occurred during the instant offense in
February 2014. He often complained that the prescribed pain medication (Tylenol) was
ineffective. Eventually, the inmate underwent surgery on February 1, 2017 to remove the
remaining bullet fragments in his skull. The surgery was successful, but because the inmate
committed suicide approximately six weeks later, it was unknown if he experienced a decrease in
pain.
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide. However, the review found several
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factors that might have been contributory to his death. For example, the inmate began to incur
RVRs beginning in September 2016 related to drug possession. As a result, he lost his job and
his points were increased, necessitating a pending transfer to a Level IV institution. Clinical
notes in both December 2016 and March 2017 indicated an increase in depression and anxiety.
The inmate also was thought to have incurred drug debts from a gang. Finally, the medical hold
from his surgery was removed several days prior to his suicide, resulting in clearance for transfer
to a Level IV facility.
The Suicide Report contained eight recommendations for corrective action through a QIP:
1) The CDCR 837s submitted by responding staff identifies approximately 30
minutes elapsed between the time the inmate was observed bleeding profusely in
his cell and his arrival in the TTA.
2) Activation of the Emergency Medical System (calling 911) did not take place
until approximately 35 minutes into the emergency, which caused a significant
delay in appropriate medical response. Additionally, Local Operational
Procedure (LOP) #8, as submitted by CMF, is outside of the Department’s
expectation that all staff have the responsibility and authority to call 911. LOP #8
identifies four classifications of employees who will make the determination a
Code 3 ambulance is required. These positions in turn must contact the Watch
Commander who is the designated contact to call 911. The steps create a
potential for delay in providing adequate care.
3) During the autopsy a suicide note alleging staff misconduct was discovered
among the contents of the inmate’s stomach.
4-6) Three nursing concerns were identified. The concerns (relating to EMS
activation and documentation during the emergency) were considered
contributory to the death.
7) The primary mental health clinician did not document consideration of
placement in a higher level of care despite the patient’s report of higher levels of
depression and anxiety during consultations in December 2016 and March 2017.
8) The treatment plan for the patient did not adequately address depression and
anxiety in the frequency of intervention offered, or in adjusting the frequency of
intervention, or in adjusting the targets of intervention, despite evidence that
symptoms were increasing or at high levels.
In the second case (CMF 9), the inmate was found hanging from the ventilation grate by a piece
of cloth in his MHCB room during the late afternoon of August 29, 2017. He was on Suicide
Watch status (i.e., 1:1 observation) at the time of his death. The inmate entered the CDCR
system on April 1, 2015 for his second term to serve a life sentence with eligibility for parole for
murder. He was transferred to CMF on June 9, 2017 to enter the PIP. The inmate incurred 21
RVRs, many of which were for assaultive behavior. The most recent RVR occurred on August
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8, 2017 and involved the assault of several medical technician assistants. In addition, two district
attorney referrals for indecent exposure were pending at the time of the inmate’s death. The
inmate was known to be gang-affiliated. He had limited family support and received a visit from
a family friend in April 2017. The inmate was unmarried and had three children from three
different prior relationships.
According to available records, the inmate was raised in a very dysfunctional family. In fact, he
was born to parents who were approximately 15-years-old. Both parents were involved in the
criminal justice system and had histories of substance abuse. Records also indicated that the
inmate had been neglected and physically abused by his mother, resulting in his placement, along
with several siblings, in foster care. He subsequently became gang-affiliated, involved in the
juvenile justice system, as well as experienced substance abuse.
The inmate had an extensive history of mental health treatment in the community for ADHD,
Bipolar Disorder and Depressive Disorder. He was not consistently medication compliant in the
community. Although he frequently expressed suicidal ideation and threatened suicide during an
earlier confinement within the Department of Juvenile Justice, the inmate did not have a
documented history of suicide attempts prior to CDCR confinement (although he self-reported
two suicide attempts by hanging at ages 16 and 18). In addition, there was documentation to
indicate that his brother and grandmother both committed suicide.
Upon entry into CDCR in April 2015, the inmate was placed at the 3CMS level of care with an
initial diagnosis of Mood Disorder. Three months later on July 28, 2015, he was placed in an
MHCB. Subsequent MHCB placements occurred in November 2015, May and June 2016,
November and December 2016, and May and August 2017. The inmate was also treated at the
PIP level of care on two occasions: from December 11, 2015 through May 16, 2016 and June 9,
2017 through August 10, 2017. He was elevated to EOP level of care in August 2015 and
remained at that level when not in MHCB or PIP placements. The inmate’s diagnoses were
adjusted throughout his CDCR term, with the most recent diagnoses in August 2017 being
Adjustment Disorder with Mixed Disturbance of Emotions and Conduct, Mood Disorder NOS,
and Antisocial Personality Disorder. He continued to be only sporadically compliant with his
psychotropic medication.
According to the CDCR reviewer in this case, the inmate had a complex clinical presentation
throughout his treatment in the MHSDS. According to the reviewer, “The clinical presentation
from 2015 leading up to his death has common threads and themes throughout the duration of the
treatment indicating his presentation did not appear to shift throughout his time in CDCR. DSH
documentation from early 2016 indicated the inmate had a pattern of initially engaging in
treatment, then becoming dissatisfied, disengaging from clinical staff, and making conditional
threats of self-harm and harm to others.”
The inmate did, however, have a significant history of self-injurious behavior throughout his
CDCR confinement, including both May and June 2017 when he utilized pieces of safety
mattresses, blankets, safety smocks, and shoelaces as ligatures in suicide gestures. He also
ingested foreign objects (such as parts of an inhaler and sprinkler) and overdosed on drugs, often
in front of staff, on at least four other occasions in November and December 2016 and May and
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June 2017. The inmate also cut his wrists on two occasions, one in front of staff, as well as
placed a plastic bag over his head and ligature around his neck. Several of these incidents of
self-injurious behavior occurred within days of receiving an RVR and/or his anticipated transfer
and/or discharge from an MHCB or PIP placement.
As one clinician noted in an SRE dated June 20, 2017 that would unfortunately become a
premonition to the inmate’s eventual death three months later:
It appears Pt’s behaviors are driven by personality pathology (impulsivity,
mood lability, poor distress tolerance). Feeling as though he is being
ignored by staff or his perception that his needs are not being met are
likely to elicit acts of self-harm. Further, feelings of anger or distress are
likely to increase risk of Pt engaging in impulsive acts of self-injurious
behaviors…suggesting pt’s risk will fluctuate rapidly with subtle changes
in mood. Self-harm may be planned, impulsive, fabricated and/or
conducted in front of staff. As Pt has a lengthy history of self-harm
behaviors with varying motivations, it remains possible that he may one
day lethally injure himself without intent to do so.
The inmate’s last SRE was conducted on August 15, 2017 for purposes of an ICF referral. The
SRE was both inaccurate and incomplete, with acute risk of suicide estimated as “moderate” and
the check box for chronic risk left blank. Several risk factors were not listed, and there was no
formulation of risk. According to the CDCR reviewer, “The safety plan for this SRE included
the referral to PIP and a lengthy list of broad treatment expectations.”
Following the inmate’s discharge from the PIP on August 10, 2017, he returned to CMF and was
placed in the administrative segregation unit. The following day (August 11), he threatened
suicide and was placed in the MHCB. Several days later on August 15, the treatment team
recommended an ICF referral. He remained in the MHCB pending the referral. On August 29,
the inmate was informed during his IDTT meeting that the ICF referral had been denied and that
the treatment team was planning on discharging him back to administrative segregation. Shortly
thereafter, the inmate became very upset and threatened suicide, stating “I am going to hang
myself.” Suicide Watch was ordered, but the inmate had already been returned to his room and
refused to relinquish his clothing and other possessions. Due to the inmate’s history of assaultive
behavior, correctional staff chose not to initiate use of force to retrieve the inmate’s clothing and
issue a safety smock. Therefore, the 1:1 observation was initiated at approximately 10:30 a.m.
with the inmate retaining his clothing and possessions. Within minutes, he began to attempt to
thread a piece of cloth through the ventilation grate in his MHCB room. According to nursing
notes, the inmate continued to periodically engage in this behavior over the next several hours in
the presence of both nursing and correctional personnel. At approximately 4:30 p.m., a nursing
note reflected that the inmate was tying a piece of string from his blanket around his neck.
Correctional personnel were notified and attempted to speak with the inmate. Approximately 20
minutes later at 4:50 p.m., an emergency response was initiated, and correctional and medical
personnel entered the room.

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As the inmate was on Suicide Watch at the time of his death, his obvious risk of suicide was
known to various MHCB personnel. As stated by the CDCR reviewer in this case, “regardless of
his varying motivations, whether intentional or impulsive, he remained a high risk for
suicide….This incident does not appear to be a response to an intent to die, rather a means to
stop his discharge to ASU. Although this dangerous behavior had previously served to be
effective for him, it would prove to become a lethal means that ultimately led to his death by
suicide.” In addition, although the inmate had several medical issues, including difficulty
walking caused by being shot in the leg during his commitment offense in March 2013, these
issues were not felt to be contributory to his death.
The Suicide Report contained 23 recommendations for corrective action through a QIP:
1) The SREs conducted on December 21, 2017 and May 3, 2017 at SAC did not
accurately contain risk formulation and adequate safety planning.
2) The SRE conducted on August 15, 2017 at CMF contained inadequate risk
formulation and safety planning.
3) The inmate was admitted to the MHCB on May 3, 2017, referred to ICF on
May 25, 2017, and admitted to the PIP on June 9, 2017. There was no
documentation from SAC of an SRE completed for the MHCB discharge. Per
policy, an SRE must be completed upon discharge from an MHCB.
4-9) There were numerous custody concerns based upon the Department’s Use of
Force policy, including the lack of immediate activation of an alarm and
immediate use of reasonable force to enter the inmate’s cell to prevent self-injury,
allowance of clothing and other possessions for an inmate on Suicide Watch
status, several discrepancies and conflicting information regarding timeline, lack
of documentation and communication amongst staff throughout the day of the
incident, and the fact the inmate tested positive for methamphetamine and
amphetamines and uncertainty as to how the patient was able to obtain these
illegal drugs.
10) Due to the layout of the MHCB cells, it is all but impossible to observe the
area near the sink and vent from outside the cell. The only area with a clear view
is right in front of the windows. The mirror placed on the ceiling of the cell
distorts the objects in the cell, eliminates a clear view of blind spots. Lack of
visual observation in the cells makes it a risk for inmates who are in crisis or on a
1:1 direct observation.
Additionally, the majority of documentation provided by CMF gives descriptive
information regarding what is observed while outside the cell during the 1:1
observation. Based on the layout it is very difficult to have observed what is
written in reports without having the cell door open. This brings into question the
accuracy and integrity of the documentation provided.

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11) Failure to activate EMS immediately was determined to be outside of CMF’s
Local Operational Procedure for Emergency Medical Response Review Policy
and Procedure, Plan #8, revised January 2017.
12) A piece of no-tear safety blanket was utilized by the inmate to fashion the
noose. The safety blanket found in the inmate’s property was fully intact. Linen
exchange was conducted on second watch the previous day and there was no
documentation indicating the inmate exchanged and altered safety blanket.
13-23) There were numerous nursing concerns, including deficiencies in
medication administration, nursing assessment, implementation of provider
orders, appropriate nursing care, and related activation of emergency response.
20)

California Men’s Colony (CMC)

Inspection: January 16-17, 2018 (previous suicide prevention audit on August 18-19, 2016).
CMC housed approximately 4,023 inmates at the time of the on-site assessment.
Screening/Assessment: This reviewer observed a few new admissions during the intake
screening process in the R&R unit on January 17, 2018. The nurse was observed to be asking all
of the questions and correctly entering the information into the EHRS. However, the door to the
nurse’s office was open during the process, with an officer straddling the doorway, thus
compromising privacy and confidentiality. The nurse informed this reviewer that they were
reluctant to have the door closed during intake screening of maximum-security and
administrative segregation unit inmates. Although this concern was certainly reasonable, a
common solution implemented in other facilities would be to install a TTM in the nurse’s office.
In addition, this reviewer observed daily PT rounds in the administrative segregation unit
(Building 4) on January 16. The rounds were unremarkable, and the PT was observed to be
correctly entering the Psych Tech Daily Rounds information into the EHRS for all caseload
inmates. Of note, however, there were numerous complaints by inmates about the lack of radios
on the unit (which did not have any electrical outlets).
Housing: CMC had a 50-bed MHCB unit. All the rooms continued to be suicide-resistant. The
administrative segregation unit contained 16 new intake cells that were retrofitted to be suicideresistant. During inspection of this unit, this reviewer observed that there were at least five new
intake inmates housed in unsafe, non-new intake cells despite the fact that several new intake
cells were empty. Although this reviewer was informed that there had been a recent riot in CYard resulting in an influx of administrative segregation inmates, there was no reason for there to
be any empty new intake cells.
Finally, alternative housing cells to temporarily house inmates identified as suicidal and
awaiting MHCB placement were found in Building 7, a location formally utilized as an interim
unlicensed MHCB unit. Alternative housing was used on a daily basis, and inmates were all
furnished beds and observed at staggered 15-minute intervals (because all of the cells were
previously found to be suicide-resistant when it was utilized as an unlicensed MHCB unit).
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From October 1 through December 31, 2017, there were approximately 176 inmates placed in
alternative housing, and the vast majority (98 percent) was released within 24 hours. Most (88
percent) were transferred to a MHCB. The overall length of stay in alternative housing for these
176 inmates was 12 hours.
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCB unit. In addition, patients not on suicide observation status were observed at 15-minute
intervals by nursing staff. This reviewer subsequently verified the accuracy of observation
rounds by reviewing the EHRS charts of four patients (CMC 1, CMC 2, CMC 3, and CMC 4) on
Suicide Precaution status in the CTC during a nine-hour period from 12:00 a.m. through 8:59
a.m. on January 13 (for CMC 1), January 15 (for CMC 2), January 16 (for CMC 3), and January
17 (for CMC 4). The chart review found only a few observation checks (i.e. between two and
five per patient) that were in excess of required 15-minute intervals, with the longest gap
between checks being 30 minutes in one case (CMC 1).
This reviewer observed nine IDTT meetings in both the A and B units of the MHCB unit on
January 16 and 17. All patients were observed to be clothed and received possessions and
privileges consistent with their respective observation levels. There were several RTs assigned
to the MHCB unit, and yard and other out-of-cell activities were utilized seven days a week.
The IDTTs were well represented by mental health, medical, and custody staff. In fact, during
IDTT meetings in B-Unit on January 17, the entire MHCB unit treatment team was in
attendance, including multiple psychologists and psychiatrists. There were robust discussions in
most cases regarding MHCB treatment and possible referrals to higher levels of care. The
assigned CC I was active in attempting to problem-solve several cases of patients with custody
issues. There was, however, uneven discussion of adequate safety planning for the three patients
being considered for discharge from the MHCB. In one case (CMC 5), for example, the patient
was admitted into the MHCB on January 5, 2018 for suicidal ideation and grave disability after
setting a fire in his cell. Although consistently reporting suicidal ideation, he vacillated between
stating the fire-setting was a suicide attempt and accident. He remained in the MHCB for 12
days and, during his IDTT meeting attended by this reviewer on January 17 (which resulted in
his discharge to administrative segregation), there was limited discussion about safety planning
other than to prepare the patient for the administrative segregation unit placement and encourage
him to stay on his psychotropic medication. There was no discussion during the IDTT meeting
about any strategies for reducing suicidal ideation nor did the resulting SRASHE contain a safety
plan:
No suicide ideation or history. Was started on injectable medication today and
IDTT reinforced the need for continued compliance, as evidenced by recent
decompensation when he did stop the medications. The thought of getting IP
back into his work program to increase pride and self-esteem and to decrease
distractions or disruptions of his symptoms (sic). It was also recommended today
that should it become known that IP has not complied with his medication regime,
that he be screened for the need of a higher level of care, based on recent events.
IP was very cooperative with all suggestions by MH psychiatry. The MHA was
completed by author of this treatment plan and it was clear to me that mental
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health played a part in the action, that he would likely decompensate in segregated
housing and that had IP been properly medicated, the behavior may not have
occurred. I will ask my supervisor to review this case and suggest documenting
the behavior in an alternative fashion.
Of note, review of the first day of the required Five-Day Follow-Up progress note dated January
18 did include some evidence of safety planning for this patient: “IP reports that he was not in
contact with his children for an extended period of time, this may trigger SI. IP plans to cope by
exercising, remaining med compliant, and talking to family. IP plans to contact PC or CO if he
has plans to self-harm/if in mental health crisis.”
Finally, a review of Guard One data for a recent 24-hour period in the administrative segregation
unit found 98-percent compliance with the required checks that did not exceed 35-minute
intervals.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS for the period of July 1 through
December 31, 2017. The TTA log for October and November 2017 was also reviewed. This
reviewer’s sample EHRS review of 49 emergency mental health referrals for suicidal
ideation/behavior revealed that clinicians completed the required SRASHEs in 94 percent (46 of
49) of the cases.
This reviewer examined a sample of ten SRASHEs from patients released from a MHCB
between October and December 2017. Overall, although there was uneven discussion of
adequate safety planning to reduce suicidal ideation, many of the safety plans showed promise as
exemplified by the following case (CMC 6):
IP is being discharged to EOP LOC at this time by the treatment team. IP will be
returning to CMC’s ASU EOP HUB…..IP acknowledged he has a pattern of
using Alt. Housing as a ‘break’ from ASU but has been working to increase his
positive coping skills he can use when distressed which would help to avoid this
pattern. IP reported the following triggers would cause him to consider suicide:
feeling depressed, being in ASU, problems with family, when not given a canteen,
when feeling paranoid…..IP is reporting that he will inform staff if he needs help
and will tell staff if he becomes suicidal at any time. IP reported his current
coping skills include: “counting to 10,” talking to psychs, listening to music,
watch TV, read, positive imagery, meditation, “having good thoughts,” and
writing. IP described his version of positive imagery (being at the beach, eating
his favorite foods, etc.) which he plans to consider when distressed. IP reports
future goals of paroling and re-entering the community. IP would like to increase
his mindfulness skills when at his next treatment team/clinician. Treatment
outcome should include identifying future positive coping skills IP can use in the
ASU setting when distressed rather than to report suicidal ideation.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
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A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 157 cases of patients discharged from a
MHCB or alternative housing placement who remained at CMC and were not transferred to
administrative segregation (where observation at 30-minute intervals was required) from July 1
through December 31, 2017. The review found that 93 percent had Page One “Discharge
Custody Check Sheet” (MH-7497) forms completed correctly by mental health clinicians, with
approximately 74 percent of the custody checks recommended for 24 hours by clinicians. In
addition, 99 percent of the “custody check” forms (Page Two) were completed correctly by
correctional staff at 30-minute intervals.
Intervention: All toured housing units contained an emergency response bag that included a
micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (September through
November 2017) found that quorums were achieved in all three meetings. Attendance averaged
between 18 and 22 members. Meeting minutes were informative and included a robust case
presentation each month.
Training: According to training records, 99 percent of custody staff and 100 percent of nursing
staff were currently certified in CPR. In addition, 99 percent of custody staff, 96 percent of
medical staff, and 61 percent of mental health staff received annual suicide prevention block
training during 2017. Finally, as of December 2017, 93 percent of mental health clinicians had
completed the SRE mentoring program, 92 percent had received the seven-hour SRE training,
and 95 percent had completed safety plan training.
Recent Suicides: CMC did not experience any inmate suicides during the review period.
21)

Pleasant Valley State Prison (PVSP)

Inspection: February 6-7, 2018 (previous suicide prevention audit on May 12-13, 2016). PVSP
housed approximately 3,182 inmates at the time of the on-site assessment.
Screening/Assessment: This reviewer observed a few new admissions during the intake
screening process in the R&R unit on February 7, 2018. The nurse was observed to be asking all
of the questions and correctly entering the information into the EHRS. The nurse’s office door
was closed during the process, an officer was stationed in the hallway, and privacy and
confidentiality were maintained.
In addition, this reviewer observed daily PT rounds in STRH unit on February 7. The rounds
were unremarkable, and the PT was observed to be correctly entering the Psych Tech Daily
Rounds information into the EHRS for each caseload inmate.
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Housing: PVSP had six MHCBs. All the rooms continued to be suicide-resistant. The STRH
unit contained six new intake cells (100-105) that were retrofitted to be suicide-resistant. During
inspection of this unit, this reviewer observed that there were three new intake inmates housed in
unsafe, non-new intake cells despite the fact that three new intake cells were empty. The
placement of new intake inmates in unsafe non-new intake cells was also found during the 2016
assessment.
Finally, alternative housing cells to temporarily house inmates identified as suicidal and
awaiting MHCB placement was infrequently utilized at PVSP. When utilized, inmates on
alternative housing status were housed in either CTC medical beds or TTA cells. Inmates were
provided stack-a-bunks and observed on a 1:1 basis. From June 1, 2017 through January 31,
2018, there were only 35 inmates placed in alternative housing, with the vast majority (88
percent) released within 24 hours. Most were transferred to an MHCB. The overall length of
stay in alternative housing for these 35 inmates was 12 hours.
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCB unit. In addition, patients not on suicide observation status were observed at 15-minute
intervals by nursing staff. This reviewer subsequently verified the accuracy of observation
rounds by reviewing the EHRS charts of four patients (PVSP 1, PVSP 2, PVSP 3, and PVSP 4)
on Suicide Precaution status in the CTC during a nine-hour period from 12:00 a.m. through 8:59
a.m. on January 23 (for PVSP 1), January 29 (for PVSP 2), and February 6 (for PVSP 3 and
PVSP 4). The chart review found numerous observation checks (i.e. between 11 and 14 per
patient) that were in excess of required 15-minute intervals, with the longest gap between checks
being 55 minutes in one case (PVSP 1). The following case (PVSP 2) exemplified the
significance of the problem: There were 12 violations of 47-, 29-, 40-, 47-, 25-, 23-, 34-, 18-,
30-, 19-, 18-, and 30-minute gaps between the required 15-minute intervals. Violations in these
four cases were committed by multiple nursing staff.
This reviewer observed two IDTT meetings in the MHCB unit on February 6. Although the
treatment team was well represented by mental health, medical, and custody staff, one of the
discussed cases was very problematic. In that case (PVSP 3), the patient had been admitted into
the MHCB on January 26 for suicidal ideation with a plan (“to use razors to cut his wrist”). His
diagnosis was Bipolar Disorder with depressed mood. The patient had stopped taking his
psychotropic medication a few months earlier which resulted in increased depression and
suicidal ideation. He was at the 3CMS level of care and had a previous MHCB admission during
2017. According to a recently completed SRASHE, the patient was assessed as having both a
“moderate” chronic and acute risk for suicide based on risk factors that included a prior suicide
attempt, family history of suicide, increased depression, and ongoing auditory hallucinations.
During the IDTT meeting on February 6, the patient was observed to be in “full-issue” clothing
but had not been granted any privileges other than periodic showers. Although he denied any
current suicidal ideation or auditory hallucinations, there was no discussion regarding safety
planning.
Following the IDTT meeting, this reviewer asked the treatment team why the patient had not
received consideration for any privileges during his 12-day MHCB stay. The PC replied that
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privileges had not been granted until today (February 6) because “he was still experiencing
hallucinations.” When this reviewer then asked if the patient was going to remain in the MHCB
unit or referred to a higher level of care, the response was that the patient had just been
discharged to EOP level of care. Such a response was surprising since it was not discussed
during the IDTT meeting. Subsequent review of the patient’s discharging SRASHE dated
February 6, 2018 found the following safety plan:
IP was educated and encouraged to participate in groups, and 1:1 individual
therapy with his PC. Based on hx, when non-medication compliant, IP may
experience an exacerbation of sxs of psychosis, depression, SI, anxiety and PI that
become unmanageable for him, as he has previously exhibited poor coping skills
in managing these sxs in the past. IP can benefit from participating in groups or
classes to develop skills to help with medication compliance, distress tolerance,
reality testing, and substance abuse issues. IP was encouraged to inform his PC if
he experiences any, or an increase in any of the following: depression, anxiety,
psychosis, and/or suicidality.
This safety plan was not only problematic, but never discussed during the February 6 IDTT
meeting.
Subsequent review of ten records (including the “CDCR-114: Inmate Segregation Record” and
daily “Order Requisition” forms”) of patients discharged from the MHCB unit found that out-ofcell privileges (e.g., a dayroom or therapeutic module) were granted by the IDTT in only 50
percent of the cases. A related discussion with a MHCB custody supervisor revealed that
although patients had been approved for dayroom or therapeutic module out-of-cell activity, the
IDTT rarely approved yard privileges (even for non-administrative segregation patients). This
reviewer’s preceding assessment contained a lengthy discussion regarding the absence of
possessions and privileges afforded to MHCB patients. To date, the problem had not been
resolved, and PVSP still did not have an RT assigned to the MHCB unit, another deficiency
found during the 2016 assessment.
Finally, a review of Guard One data for a recent 24-hour period in the STRH unit found 98percent compliance with required checks that did not exceed 35-minute intervals.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS for the period of August 1, 2017
through January 31, 2018. This reviewer’s sample EHRS review of 36 emergency mental health
referrals for suicidal ideation/behavior revealed that clinical staff completed the required
SRASHEs in only 81 percent (29 of 36) of the cases.
This reviewer also examined a sample of ten SRASHEs of patients released from the MHCB unit
from November 2017 through January 2018. Similar to the 2016 assessment, development of
safety plans for patients discharged from the MHCB unit continued to be problematic. For
example, the discharging SRASHEs for three different patients (PVSP 5 and PVSP 6 on January
4, 2018, and PVSP 7 on January 25, 2018) by the same MHCB clinician contained the same
safety plan:
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Treatment plan will include IP’s practice of effective coping and motivational
strategies. Therapeutic interventions will include:
1. PC will continue empathetic support for IP. PC will meet with IP as
scheduled/requested.
2. PC-led instruction and practice in the use of CBT-based hypothesis testing and
reframing interventions addressing any recurrent negative automatic thoughts
experienced by IP.
4. Referral to psychiatry if appropriate (IP is not currently prescribed psychiatric
medications).
5. Ongoing evaluation by PC to determine appropriateness for reduction in LOC
to least restrictive environment (non-MHSDS).
Of note, the above safety plans were miss-numbered in each case.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of ten cases of patients discharged from a
MHCB unit or alternative housing placement who remained at PVSP and were not transferred to
the STRH unit (where observation at 30-minute intervals was required) from August 1, 2017
through January 31, 2018. The review found that 70 percent had Page One of the “Discharge
Custody Check Sheet” (CDCR MH-7497) completed correctly by mental health clinicians, with
most of the custody checks recommended for only 24 hours by clinicians. In addition, 90
percent of the “custody check” forms (Page Two) were completed correctly by correctional staff
at 30-minute intervals.
Intervention: All toured housing units contained an emergency response bag that included a
micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (October through
December 2017) found that a quorum was achieved in only one meeting (December). The
meeting minutes were otherwise unremarkable.
Training: According to training records, 100 percent of both custody and nursing staff were
currently certified in CPR. In addition, 100 percent of custody staff, 89 percent of medical staff,
and 88 percent of mental health staff received annual suicide prevention block training during
2017. Finally, as of January 2018, 100 percent of mental health clinicians had completed the
SRE mentoring program, 96 percent had received the seven-hour SRE training, and 100 percent
had completed safety plan training.
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Recent Suicides: PVSP did not experience any inmate suicides during the review period.
22)

Salinas Valley State Prison (SVSP)

Inspection: February 8-9, 2018 (previous suicide prevention audit was on June 7-9, 2016).
SVSP housed approximately 3,523 inmates during the on-site assessment.
Screening/Assessment: This reviewer observed a few new admissions during the intake
screening process in the R&R Unit on February 9, 2018. The nurse was observed to be asking
all of the questions and correctly entering the information into the EHRS. The nurse’s office
door was closed during the process, an officer was stationed in the hallway, and privacy and
confidentiality were maintained.
In addition, this reviewer observed daily rounds in portions of the administrative segregation
units (STRH, D-1, and D-8 [overflow]) on February 8. The rounds were unremarkable, and the
PT was observed to be correctly entering the Psych Tech Daily Rounds information into the
EHRS for each caseload inmate.
Housing: SVSP had a 22-bed CTC, with ten designated MHCBs. All of the MHCB rooms were
found to be suicide-resistant. Following the previous assessment, triangle-shaped stainless-steel
shelving was retrofitted to each side of the existing sinks so that any ligature would slide off
during a suicide attempt.
The three administrative segregation units (STRH, D-1, and D-8 [over-flow]) had a total of 17
retrofitted new intake cells; nine in the STRH Unit (100-108); four in D-1 Unit (117-118, 217218); and four in D-8 Unit (115-116, 215-216). During inspection of the STRH Unit, this
reviewer observed that all nine new intake cells were full and there were an additional four new
intake inmates housed in unsafe, non-new intake cells. In D-1, this reviewer did not observe any
new intake inmates in unsafe, non-new intake cells. In D-8, this reviewer observed two new
intake inmates in unsafe, non-new intake cells despite the fact that one of the new intake cells
was empty. The placement of new intake inmates in unsafe non-new intake cells was also found
during the preceding assessment.
Finally, alternative housing cells to temporarily house inmates awaiting MHCB placement were
primarily found in Facility D, Building 5 and TTA cells, as well as occasionally in other
designated cells throughout the facility. Alternative housing was used on a daily basis, and
inmates were all provided beds and observed on a 1:1 basis. From November 1, 2017 through
January 31, 2018, there were approximately 266 inmates placed in alternative housing, and the
vast majority (85 percent) was released within 24 hours. The vast majority (88 percent) were
also transferred to a MHCB. The overall length of stay in alternative housing for these 266
inmates was 15 hours. Of note, alternative housing practices at SVSP had dramatically improved
since this reviewer’s preceding assessment.
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCBs. All other patients not on a level of suicide observation were required to be observed at
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staggered 30-minute intervals. This reviewer subsequently reviewed the accuracy of observation
rounds by reviewing the EHRS charts of four patients (SVSP 1, SVSP 2, SVSP 3, and SVSP 4)
on Suicide Precaution status in the CTC during a nine-hour period from 12:00 a.m. through 8:59
a.m. on December 29, 2017 (for SVSP 1), February 5, 2018 (for SVSP 2), February 7, 2018 (for
SVSP 3), and February 8, 2018 (for SVSP 4). The chart review found numerous observation
checks (i.e. between 13 and 17 per patient) that were in excess of required 15-minute intervals,
with the longest gap between checks being 68 minutes in one case (SVSP 1). The following case
(SVSP 2) exemplified the significance of the problem: There were 14 violations of 21-, 18-, 27-,
19-, 23-, 28-, 21-, 19-, 28-, 26-, 53-, 22-, 18-, and 16-minute gaps between the required 15minute intervals. Violations in these four cases were by multiple nursing staff. One possible
reason for these multiple violations was that nursing staff was documenting checks at only four
intervals per hour.
Due to a low MHCB census, this reviewer was only able to observe two IDTT meetings during
the on-site assessment. One meeting had to be postponed because the patient became agitated
and uncooperative. The other meeting included a robust and interactive discussion by most
treatment team members, but the case did not involve a patient eligible for discharge, therefore,
there was not any meaningful discussion regarding safety planning. Review of records indicated
that most patients were approved for shower, yard, and telephone privileges, but out-of-cell
activities were very limited. There were multiple RTs providing coverage in the CTC that was
divided among MHCB and medical patients. Although an FTE RT was not available exclusively
for MHCB patients, a larger problem was the RTs had very little program space other than trying
to schedule out-of-cell time in medical and mental health staff offices. In addition, the CTC yard
did not have a “small management” module, therefore, patients on maximum-security and/or
administrative segregation status were never provided access to the yard.
Finally, a review of Guard One data for a recent 24-hour period found 92-percent compliance
with required checks not exceeding 35 minutes in the STRH unit, whereas the D-1 unit was at
98-percent compliance.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS for the period of November 1, 2017
through January 31, 2018. This reviewer’s sample EHRS review of 60 emergency referrals for
suicidal ideation/behavior revealed that clinical staff completed the required SRASHEs in 95
percent (57 of 60) of the cases. This was an improvement from the preceding assessment.
This reviewer also examined a sample of ten SRASHEs from patients released from the MHCB
unit during the period of November 2017 through January 2018. Many of the safety plan
sections of these discharging SRASHEs contained some discussion regarding specific coping
skills and strategies for reducing recurrence of suicidal ideation. One particular case (SVSP 5)
contained the following noteworthy and comprehensive safety plan:
1) Patient is discharged to the ICF LOC, while being housed in EOP-ASU
pending placement. Upon arrival to EOP, patient will be seen on custody wellness
checks and a 5-day clinical follow-up.

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2) A Safety Planning card was established with and given to Pt which delineates
the following:
•
•
•
•
•

Pt’s reason for living: hopes of getting a job one day and learning
to read.
People or things Pt can turn to: I want to work in the kitchen and
can talk to the workers.’
The first person Pt contacts when feeling the stress is his clinician,
though articulates ability to communicate to ‘anyone’ in an
emergency.
Ways Pt can cope include: breathing, art, increasing his activity,
making sure he takes his medications.
Warning signs Pt has identified include: ‘feeling suicidal with a
plan to hurt myself or if I can control the voices even after I have
tried to distract for an hour.’

3) Patient is currently prescribed Remeron 30mg and Zyprexa 20mg with a PRN
of Zyprexa 5mg. He continues to hear voices but noted improvement with
medication and denies current side effects. It is recommended that his future
treatment team closely monitor auditory hallucinations and respond with
medication as appropriate.
4) Treatment team recommends his PC follow-up with any possible classes to
help him learn how to read. He has expressed a desire to learn, saying the skill
would help him when he paroles. If program is available, Pt would benefit from
daily support.
5) Pt has identified that yoga and stretching has helped them in the past and
motivates him to do more activity and would benefit from daily practice in his
cell.
6) Patient has been educated on abdominal breathing while in MHCB and
indicates that it helps him to distract from AH; it is recommended that his future
PT continues to teach and reinforce daily use of breathing exercises.
7) It is recommended that his tx team continue to model, educate Pt on, and
reinforce adaptive means of getting his needs met, include effective
communication skills and changing cognitive distortions to include realistic
expectations of others. He also has worked on art therapy, which has been
effective in reducing distress from AH.
8) IP will let any staff member know immediately should he experience
unmanageable SI.
Although review of the subsequent first day of the five-day follow-up assessments in these ten
cases did not always find concordance with the safety plan narrative contained in the discharging
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SRASHEs, there was demonstrated progress with safety planning compared to the preceding
assessment. It was noteworthy that, effective July 31, 2017, a memorandum was issued by
mental health leadership at SVSP that required “all safety plans as documented in the Suicide
Risk Evaluation conducted on the date of the patient’s clinical discharge from MHCB must be
reviewed and positively cleared/approved by the MHCB Senior Psychologist, Supervisor or
designee.” As previously detailed in this report, such a directive became a system-wide
requirement within CDCR in January 2018.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with documentation of 201 cases of inmates discharged from either
the MHCB unit or alternative housing who remained at SVSP and were not transferred to
administrative segregation (where observation at 30-minute intervals was required) during the
months of July, August, November, and December 2017. The review found that only 50 percent
had Page One of the “Discharge Custody Check Sheet” (MH-7497) forms completed correctly
by mental health clinicians, with most custody checks recommended for 48 hours by clinicians.
In addition, only 63 percent of the “custody check” forms (Page Two) were completed correctly
by correctional staff at 30-minute intervals. Noted deficiencies were that either Page One of the
forms was blank or custody checks were ordered for less than 24 hours, and correctional staff
was not consistently completing checks during the First Watch.
Of note, although SVSP internal audits of the “Discharge Custody Check Sheet” (MH-7497)
forms invariably reported higher compliance rates during monthly SPRFIT meeting minutes
from November 2017 through January 2018, these audits were limited to the quantity of forms
collected, and not the quality of documentation (with accompanying deficiencies). Similar low
compliance rates were found during the 2016 assessment. Finally, as detailed below,
problematic completion of the “Discharge Custody Check Sheet” (MH-7497) forms by both
mental health and correctional personnel was a notable deficiency cited in a recent SVSP inmate
suicide (SVSP 6) in December 2017.
Intervention: All toured housing units contained an emergency response bag that included a
micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (November 2017
through January 2018) found that quorums were not achieved in any of the meetings. The
meeting minutes included a corrective action plan regarding this reviewer’s previous assessment
and were otherwise unremarkable.
Training: According to training records, approximately 99 percent of custody and 100 percent
of nursing staff were currently certified in CPR. In addition, 99 percent of custody staff, 100
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percent of medical staff, and 99 percent of mental health staff received annual suicide prevention
block training during 2017. Finally, as of January 2018, 100 percent of mental health clinicians
had completed the SRE mentoring program, 83 percent had received the seven-hour SRE
training, and only 75 percent had completed safety plan training. Of note, compliance rates for
annual suicide prevention block training of both medical and mental health personnel were
significantly improved since the 2016 assessment.
Recent Suicides: SVSP experienced one inmate suicide during the review period. In that case
(SVSP 6), the inmate was found hanging from the upper bunk by a sheet in his SNY cell during
the late afternoon of December 9, 2017. The inmate entered the CDCR system on February 27,
2009 to serve a 26-year sentence for multiple counts of rape with force, oral copulation with
force, and use of a firearm. He was transferred to and from SVSP on several occasions, most
recently on December 7, 2017, two days before his death. There were conflicting reports
regarding any gang affiliation by the inmate. He had seven RVRs, including battery on an
inmate in January 2012 that resulted in conviction. The inmate’s most recent RVR occurred in
August 2017 and involved alteration of state clothing. He was never married and did not have
any children, although the inmate had the family support of his father and stepmother through
visits and telephone calls.
According to available records, the inmate was born and raised in Mexico. His parents divorced
when he was 5-years-old. His mother left the family and he, along with three sisters, remained in
the care of his father who eventually remarried. The inmate was viewed as an unreliable historian
and entered the United States either in 1998 or 2003 according to varying self-reports. He did
not complete high school and worked as a manual laborer. The inmate began to abuse both
alcohol and drugs at age 13, and his family had a history of substance abuse. Prior to the instant
offense, he had several arrests for non-violent offenses. There was no record of the inmate
receiving any mental health treatment in the community.
Upon his entry into CDCR, the inmate requested SNY status due to the instant offense. In
March 2011, the inmate was placed at the 3CMS level of care following reports of “mood
instability, fighting with cellmates, dramatic outbursts, and tangential thinking/confusion.” His
initial diagnoses were Depressive Disorder NOS (provisional) and Antisocial Personality
Disorder.
The inmate was prescribed psychotropic medication, but he struggled with both medication
compliance and group treatment. In February 2012, the inmate complained of hearing voices
telling him to hurt himself. According to the completed SRE, he appeared confused, agitated,
and disoriented. Both his acute and chronic risk for suicide was noted to be “moderate,” but he
was not placed in an MHCB. As time progressed, the inmate continued to endorse chronic
depressive symptoms and “stress.” He noted the voices decreased when he consistently took his
psychotropic medication. The inmate remained relatively stable until 2016 when he stopped
taking his medication and began having active mood and psychotic symptoms. In July 2016, his
level of care was elevated to EOP because his somatic delusions, auditory and visual
hallucinations, paranoia, and anxiety intensified. The inmate’s diagnoses were revised to
Schizoaffective Disorder, Depressive Type, R/O Bipolar Disorder, and Antisocial Personality
Disorder. Two months later in September 2016, he was transferred to SVSP and his level of care
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was reduced back to 3CMS, although the reason for the level of care change was not clear from
the records. His diagnoses remained the same.
In March 2017, the inmate stopped taking his psychotropic medication. He subsequently
engaged in self-injurious behavior and was placed in an MHCB at CMF on April 2, 2017. Both
his chronic and acute risk for suicide was rated as “moderate.” The inmate did not report any
prior history of suicidal behavior. He was restarted on medication and remained mostly
compliant. The inmate was discharged back to SVSP at EOP level of care on April 12, 2017.
He remained stable during the next several months. However, in October 2017, the inmate
began refusing his psychotropic medication and by November reported he was eating and
sleeping poorly due to increased auditory hallucinations and sexual urges. On November 26,
2017, the inmate was admitted into an MHCB at CHCF after reporting auditory and visual
hallucinations, depression, and suicidal ideation. He was generally uncooperative during the
placement and refused much of the treatment and afforded privileges. The inmate remained
psychotic during the ten-day MHCB stay and his diagnosis was revised to Schizoaffective
Disorder, Manic Type. His level of care was again elevated back to EOP. As noted by the
CDCR reviewer in this case, the discharging SRASHE completed on December 5, 2017 had
several deficiencies, including an inadequate safety plan.
The inmate was discharged back to SVSP on December 7, 2017. He was seen for the first day of
his five-day follow-up assessment on December 8. Although he denied any suicidal ideation, the
Mental Health Crisis Bed Discharge Custody Check Sheet was not completed by the clinician.
The following day (December 9), when a clinician arrived on the housing unit to conduct another
follow-up assessment, the inmate was found hanging in his cell. The subsequent investigation
also found that the required 30-minute custody checks were not consistently conducted as
required.
Apart from the inmate being released from an MHCB a few days earlier, the CDCR reviewer in
this case did not find any other specific precipitating factors that were known to staff indicating
that the inmate was contemplating suicide. In addition, although the inmate had several medical
problems, these issues were not thought to be contributory to his death. A subsequent interview
with a former cellmate revealed that the inmate had been acting in a bizarre manner (e.g.,
“talking to his mattress”) since his return from the MHCB. According to the CDCR reviewer,
“By his own words, the inmate had reported to mental health staff he felt suicidal when the
voices told him his family had died. In the days leading up to his death, he admitted to staff he
heard voices again telling him his family was dead. It is plausible his auditory hallucinations had
once again progressed to this point and he acted in an impulsive moment to try to end his
distress.”
The Suicide Report contained eight recommendations for corrective action through a QIP:
1) SVSP Mental Health: Several months (June through November) of 2017
clinical progress notes by the inmate’s primary clinician at SVSP were reviewed
and found lacking in sufficient detail.

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2) SVSP Mental Health PC: The Mental Health Crisis Bed Discharge Custody
Check Sheet (Form MH-7497) was not filled out by the mental health clinician.
Training has already occurred with the local SPRFIT coordinator and the clinical
staff to address the issue.
3) SVSP Mental Health: Problematic SRE/SRASHE documentation was
identified for the dates of April 17, 2017, July 12, 2017, and November 9, 2017.
4) CHCF Mental Health: Problematic SRASHE dated December 5, 2017.
5) Custody: The inmate was a Mental Health Crisis Bed Discharge from CHCF
Stockton facility. He was on a 5-day follow-up and required custodial checks at
staggered intervals which should not be routine or pattern forming, and not to
exceed 30 minutes. Reviewing the custodial checks on the day of the incident, the
last entry was at 1630 hours. The next time an officer would see the inmate was
at 1729 hours, which was the time of the incident. A whole hour had passed since
the welfare check was performed.
6) Nursing Assessment Provider 1: RN 1 did not assess patient for c/o dizziness as
a side effect to his medication. Documentation on top of 7362 reflects referral to
medical and mental health. There was no evidence to suggest patient was seen for
this complaint.
7) Nursing Assessment Provider 2: RN 2 did not assess patient for c/o feeling bad
and wanting to see psychiatrist. Patient wrote “Urgente” on top of the 7362.
There was no evidence to suggest patient was seen for this complaint.
8) There were multiple concerns with the MHCB in-patient stay at CHCF
occurring on November 26, 2017-December 7, 2017 (involving multiple
psychiatry and primary clinician deficiencies).
23)

Pelican Bay State Prison (PBSP)

Inspection: February 14-15, 2018 (previous suicide prevention audit was on September 14-16,
2016). PBSP housed approximately 2,668 inmates at the time of the on-site assessment.
Screening/Assessment: This reviewer did not have an opportunity to observe the intake
screening process because there were no new admissions during the on-site assessment. The
preceding assessment did not find any problems during the intake screening process.
This reviewer observed daily PT rounds in the STRH and GP sections of the administrative
segregation unit on February 14. The rounds were unremarkable, and the PT was observed to be
correctly entering the Psych Tech Daily Rounds information into the EHRS for each caseload
inmate. This reviewer also observed rounds by a psychologist assigned to SHU. Of note, the
PSU at the facility was closed, and the SHU program was reduced to nine housing units.

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Housing: PBSP had ten MHCBs. Due to a low census (one patient), this reviewer was able to
conduct a thorough inspection of each room. The inspection revealed a previously unidentified
deficiency of wall and ceiling ventilation grates in each room having holes that were greater than
the industry standard of 3/16 inches wide or 16-mesh per square inch. The current diameter of
the ventilation grate holes was unsafe and should be replaced. The MHCB rooms were
otherwise suicide-resistant.
The administrative segregation units had 24 retrofitted suicide-resistant cells designated for new
intake inmates, with 12 new intake cells designated in both the STRH and GP administrative
segregation sections of the unit. During inspection, this reviewer did not observe any new intake
inmates housed in non-new intake cells. In addition, three housing units in the SHU building of
Facility C were designated for administrative segregation overflow. There were no 3CMS
inmates assigned to these units, nor were new intake inmates initially assigned to these overflow
units. Of note, however, there were numerous complaints by inmates assigned to the three
overflow administrative segregation units in the SHU building about the lack of radios and
extended period of time to receive property. There were also complaints that, although there was
book distribution in both the STRH and GP sections of the administrative segregation unit, there
was little, if any, availability of books in the three overflow units. PBSP leadership was made
aware of these concerns.
Finally, alternative housing cells to temporarily house inmates awaiting MHCB placement were
primarily found in either CTC medical rooms or observation rooms within the MHCB unit.
Alternative housing was utilized on a regular, but not daily, basis. Inmates were provided stacka-bunks (correcting a problem identified during the previous assessment) and observed on a 1:1
basis. From November 12, 2017 through February 12, 2018, there were only 26 inmates placed
in alternative housing, and all were released within 24 hours. The vast majority (88 percent)
were transferred to a MHCB. The overall length of stay in alternative housing for these 26
inmates was 12 hours.
Observation: Both Suicide Watch and Suicide Precaution statuses were being used in the
MHCB unit. In addition, patients not on suicide observation status were observed at 30-minute
intervals by nursing staff. This reviewer subsequently reviewed the accuracy of observation
rounds by reviewing the EHRS charts of four patients (PBSP 1, PBSP 2, PBSP 3, and PBSP 4)
on Suicide Precaution status in the CTC during a nine-hour period from 12:00 a.m. through 8:59
a.m. on December 17, 2017 (for PBSP 1), January 9, 2018 (for PBSP 2), February 2, 2018 (for
PBSP 3), and February 11, 2018 (for PBSP 4). The chart review found numerous observation
checks (i.e. between two and ten per patient) that were in excess of required 15-minute intervals,
with the longest gap between checks being 51 minutes in one case (PBSP 3). The following case
(PBSP 2) exemplified the significance of the problem: There were eight violations of 16-, 24-,
32-, 34-, 50-, 31-, 22-, and 22-minute gaps between the required 15-minute intervals. Violations
in these four cases were by multiple nursing staff.
Due to a low MHCB census, this reviewer was not able to observe any IDTT meetings during the
on-site assessment. However, this reviewer was able to converse with several MHCB clinicians
and was informed that a full-time RT was assigned to the unit and able to provide out-of-cell
time of at least one to two hours to each patient, including availability of both yard and program
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office. In addition, this reviewer was informed that there was no longer confusion amongst
IDTT members regarding possessions and privileges that could be approved for MHCB patients.
However, given the significant deficiencies found during the preceding assessment, including
inadequate discussions regarding safety planning, patients never being eligible for “full-issue”
clothing, and confusion about, and restrictions placed upon, the issue of yard, telephone, and
visiting privileges, any conclusions regarding the correction of these problems will be deferred
until the next on-site assessment when various IDTT team meetings can be observed.
Finally, a review of Guard One data for a recent 24-hour period in the administrative segregation
unit (housing both the STRH and GP administrative segregation sections) found 95 percent
compliance with the required checks that did not exceed 35-minute intervals. In addition, the
combined compliance rate in the three administrative segregation overflow units located in the
SHU building of Facility C was 94 percent. A review of Guard One data for a recent 24-hour
period in a few SHUs found compliance with the required checks that did not exceed 35-minute
intervals during Second and Third Watches, and 60-minute intervals during the First Watch
(pursuant to a stipulation approved by the court on September 1, 2016) (ECF No. 5487) was a
combined 92 percent. However, these high compliance rates are tempered by the fact that an
inmate (PBSP 7) committed suicide in the GP section of the administrative segregation unit in
March 2017 and found to be in the state of rigor mortis, a clear indication that Guard One rounds
were not properly conducted.
Management/Treatment Planning: This reviewer requested and subsequently received a
listing of emergency mental health referrals from the MHTS for the period of August 12, 2017
through February 12, 2018. This reviewer’s subsequent sample EHRS review of 42 cases of
emergency mental health referrals for suicidal ideation/behavior revealed by clinical staff
completed the required SRASHEs in 93 percent (39 of 42) of the cases. This was a significant
improvement from the preceding assessment.
This reviewer examined a sample of ten SRASHEs from patients released from the MHCB unit
between September 2017 and January 2018. Although the safety plan narrative in all the
assessments was lengthy, the safety plans did not consistently include specific strategies for
reducing suicidal ideation. For example, in one case (PBSP 5), the patient had a history of
suicidal ideation and prior MHCB admissions. The safety plan stated: “Recommended outpatient intervention(s) include CBT to increase insight into cognitive distortions/thinking errors
and how this triggers distorted decisions and poor self-care, by learning the 10 cognitive
distortions and identifying 3 to begin interrupting when those thoughts occur, to practice daily;
MI to explore IP commitment to change or choice to continue with repetitive destructive
actions/choices/beliefs; use CBT to develop 3 new coping skills within the next 30 days that help
to improve functioning and increase confidence.” In another case (PBSP 6), the same clinician
developed the following safety plan for a patient with a “high” chronic risk for suicide:
“Recommended out-patient intervention(s) is communication skills/problem-solving skills to
express his concerns appropriately instead of reporting SI; psychoeducation on 2 relaxation
techniques over 90 days to reduce anxiety; CBT to identify distorted thoughts associated with
anxiety/SI; 2 mindfulness techniques to accept negative emotions/thoughts and 2 defusing
techniques over 90 days to reduce impact of negative thoughts.”

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Instead of deferring the development of these techniques and strategies to outpatient clinicians,
development of specific strategies to reduce suicidal ideation was the responsibility of the
MHCB clinicians. Overall, although development of adequate safety plans was uneven, there
was an improvement since the prior assessment.
Finally, the process by which inmates were provided “discharge custody checks” at 30-minute
intervals following release from either a MHCB or alternative housing placement was reviewed.
A two-page “Discharge Custody Check Sheet” (CDCR MH-7497) was required to be completed
on each inmate. The first page contained “discharging information” that was completed daily by
the mental health clinician when determining whether the 30-minute custody checks were to be
continued up to 72 hours. The second page represented the “custody checks” form completed by
custody staff.
This reviewer was presented with 22 cases of patients discharged from the MHCB unit or
alternative housing placement who remained at PBSP and were not transferred to the
administrative segregation unit or SHU (where observation at 30-minute intervals was required)
from January 1, 2017 through February 10, 2018. The review found that only the 68 percent had
Page One of the “Discharge Custody Check Sheet” (CDCR MH-7497) forms completed
correctly by mental health clinicians, with almost all of the custody checks recommended for
only 24 hours by clinicians. In addition, 95 percent of the “custody check” forms (Page Two)
were completed correctly by correctional staff at 30-minute intervals. Most of the deficiencies in
completion of the forms by mental health clinicians were attributable to recommending
discontinuation of custody checks in less than the required 24 hours.
Intervention: All toured housing units contained an emergency response bag that included a
micro-shield, Ambu bag, and cut-down tool.
SPRFIT Meetings: A review of three months of SPRFIT meeting minutes (November 2017
through January 2018) found that quorums were achieved in all of the meetings (although a
Correctional Health Services Administrator was not in attendance at any of the meetings because
the position was frozen). Meeting minutes were otherwise unremarkable. This reviewer
observed the SPRFIT meeting on February 14, 2018.
Training: According to training records, 99 percent of both custody and nursing staff were
currently certified in CPR. In addition, 96 percent of custody staff, 99 percent of medical staff,
and 100 percent of mental health staff received annual suicide prevention block training during
2017. Finally, as of January 2018, 90 percent of mental health clinicians had completed the SRE
mentoring program, 100 percent had received the seven-hour SRE training, and 100 percent had
completed safety plan training.
Recent Suicides: PBSP experienced one inmate suicide during the review period. In that case
(PBSP 7), the inmate was found hanging from a light fixture by a sheet in his administrative
segregation cell during the morning of March 23, 2017. He was found in the state of rigor
mortis. The inmate entered the CDCR system for a second term on January 29, 2015 to serve a
six-year sentence for carjacking, with enhancements for use of a firearm. He was transferred to
PBSP on May 7, 2015 and scheduled for parole in December 2017. The inmate incurred only
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one RVR during his confinement, a battery on another inmate occurring on February 15, 2017.
As a result of that incident, the inmate was placed in administrative segregation and remained
there for safety concerns pending transfer to another prison. He was gang-affiliated, and the
incident involved battery of a rival gang member. The inmate was never married and did not
have any children. He enjoyed good family support that was reflected in letter correspondence,
telephone calls, and visits.
According to limited available records, the inmate was raised by both parents and had three
siblings. He was reportedly a good student in grade school but was subsequently expelled for
drug use. He became gang affiliated at age 14 and soon accumulated a juvenile arrest record.
He subsequently worked with his father in a variety of jobs but received a five-year prison term
in 2009 for resisting arrest and evading a peace officer. He was paroled in August 2013.
According to his sister, the inmate became employed again and doing well until he started using
alcohol and methamphetamine. When using these substances, he would become paranoid,
behavior that led to the instant offense in September 2014.
The inmate did not have any reported history of mental health treatment in the community and
screened negative for any mental health symptoms upon entry into CDCR. He also did not have
any history of suicidal behavior nor did he ever express any suicidal ideation during
confinement.
The CDCR reviewer in this case did not find any specific precipitating factors that were known
to staff indicating that the inmate was contemplating suicide. He did not have any medical issues
that were thought to be contributory to his death. However, it was noted that “When the inmate
attacked a rival gang member without permission (from the gang leader), he placed himself in a
dangerous position with both the Northerners and the Southerners…. What actual information he
might have received from the leadership of either gang is not known; however, it is possible that
his life was being threatened by one or both gangs. In addition, his family may have been
threatened with harm as well. Without a suicide note, the reason will never be known with any
certainty.”
The Suicide Report contained six recommendations for corrective action through a QIP:
1) The first area of concern involves the condition in which the inmate was
discovered. Based on reports submitted by responding staff, the inmate was
discovered rigid, with obvious signs of rigor mortis and he displayed blue lips,
eyelids, fingers and toes. Vitals taken by medical staff at 0634 hours indicated the
inmate was cool to the touch and had a body temperature of 82 degrees. This
calls into question the thoroughness of the security/welfare checks completed
initially on Second Watch and those completed during First Watch. Review of
the Guard One ‘Rounds Tracker Summary’ identifies all checks were completed.
However, it appears the making of a visual/physical observation of a living,
breathing inmate, free of obvious injury as required did not occur appropriately
during either Watch.

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2) When the inmate was cut down, he fell to the floor. Staff should do anything
possible to try and relieve the pressure/weight when cutting down a victim and
support them to the ground. The Suicide Prevention Training provided by PBSP
(Chapter V, Emergency Response to a Suicide Attempt, Section B, Emergency
Responses, Responding to a Suicide), states in part, ‘Relieve tension and cut the
noose above the knot.’
3) Although a whistle was blown to summon assistance, officers did not have
their Personal Alarm Device (PAD) on their persons during the incident. The
officer yelled out for the control booth officer to activate his PAD, with no
response. The officer had to blow his whistle and run out to the rotunda to get the
control booth officer’s attention, causing a delay for both a custody and medical
response to this emergency. Per PBSP’s post orders, a PAD is part of the
Equipment/Proper Uniform to have while on duty.
4-6) Per the Nursing Review Summary, three nursing concerns were identified
that requires follow-up (responding nurses initiated CPR after noting the patient
had positive signs of rigor mortis, inadequate AED documentation, and delayed
911 activation).

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ACRONYMS and ABBREVIATIONS

3CMS:

Correctional Clinical Case Manager System

ADHD:

Attention Deficit Hyperactivity Disorder

AED:

Automated External Defibrillator

AH:

Auditory Hallucinations

Ambu bag:

Ambulatory Bag Used for CPR

APP:

Acute Psychiatric Program

ASH:

Atascadero State Hospital

ASU:

Administrative Segregation Unit

BPH:

Board of Parole Hearings

BVM:

Big Valve Mask

CAH:

Command Auditory Hallucinations

CAP:

Corrective Action Plan

CBT:

Cognitive Behavioral Therapy

CCCMS:

Correctional Clinical Case Manager System

CC I:

Correctional Counselor I

CCI:

California Correctional Institution

CCR:

California Code of Regulations

CCWF:

Central California Women’s Facility

CDCR:

California Department of Corrections and Rehabilitation

CHCF:

California Health Care Facility

CIM:

California Institution for Men

CIW:

California Institution for Women
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CMC:

California Men’s Colony

CMF:

California Medical Facility

CMH:

Chief of Mental Health

CNE:

Chief Nursing Executive

CPR:

Cardiopulmonary Resuscitation

CQI:

Continuous Quality Improvement

CQIT:

Continuous Quality Improvement Tool

CSATF :

California Substance Abuse Treatment Facility

CSP/Corcoran:

California State Prison/Corcoran

CSP/LAC:

California State Prison/Los Angeles County

CSP/Sac:

California State Prison/Sacramento

CSP/Solano:

California State Prison/Solano

CTC:

Correctional Treatment Center

DAI:

Division of Adult Institutions

DBT:

Dialectical Behavioral Therapy

D/C:

Discharge

DCHCS:

Division of Correctional Health Care Services

DSH:

Department of State Hospitals

DVI:

Deuel Vocational Institution

EHRS:

Electronic Health Record System

EOP:

Enhanced Outpatient Program

eUHR:

Electronic Unit Health Record

GP:

General Population
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HDSP:

High Desert State Prison

HRL:

High-Risk List

ICC:

Institutional Classification Committee

ICF:

Intermediate Care Facility

IDTT:

Interdisciplinary Treatment Team

IM:

Intra-Muscular

IP or I/P:

Inmate Patient or Inmate/Patient

IPE:

Initial Psychiatric Evaluation

IPOC:

Individual Plan of Care

IST:

In-Service Training

ISU:

Investigative Services Unit

KVSP:

Kern Valley State Prison

LOC:

Level of Care

LOP:

Local Operating Procedure

LPT:

Licensed Psychiatric Technician

LTRH:

Long-Term Restricted Housing

LVN:

Licensed Vocational Nurse

MCSP:

Mule Creek State Prison

MH:

Mental Health

MHCB:

Mental Health Crisis Bed

MHCBU:

Mental Health Crisis Bed Unit

MHCT:

Mental Health Compliance Team

MHOHU:

Mental Health Outpatient Housing Unit
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MHPC:

Mental Health Primary Clinician

MHPP:

Mental Health Psychiatric Provider

MHSDS:

Mental Health Services Delivery System

MHTS:

Mental Health Tracking System

NKSP:

North Kern State Prison

NOS:

Not Otherwise Specified

OHU:

Outpatient Housing Unit

OP:

Operating Procedure

PBSP:

Pelican Bay State Prison

PC:

Primary Clinician

PIP:

Psychiatric Inpatient Program

POR:

Probation Officer Report

PRN:

As Needed

PSU:

Psychiatric Services Unit

PT:

Psychiatric Technician or Psych Tech

PTSD:

Post-Traumatic Stress Disorder

PVSP:

Pleasant Valley State Prison

QIP:

Quality Improvement Plan

R&R:

Receiving and Release

RC:

Reception Center

RJD:

Richard J. Donovan Correctional Facility

RN:

Registered Nurse

R/O:

Rule Out
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RT:

Recreation Therapist

RVR:

Rules Violation Report

Rx:

Prescription

SHU:

Security Housing Unit

SI:

Suicidal Ideation

SIB:

Self-Injurious Behavior

SMHP:

Statewide Mental Health Program

SNY:

Sensitive Needs Yard

SOAPE:

Subjective Objective Assessment Plan Evaluation

SOMS:

Strategic Offender Management System

SPMW:

Suicide Prevention Management Workgroup

SPOC:

Suicide Prevention Outreach Committee

SPRFIT:

Suicide Prevention and Response Focused Improvement Team

SQ:

San Quentin State Prison

SRAC:

Suicide Risk Assessment Checklist

SRASHE:

Suicide Risk Assessment and Self-Harm Evaluation

SRE:

Suicide Risk Evaluation

STRH:

Short-Term Restricted Housing

SVSP:

Salinas Valley State Prison

Sx:

Symptoms

TTA:

Triage and Treatment Area

TTM:

Therapeutic Treatment Module

Tx:

Treatment
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UHR:

Unit Health Record

VH:

Visual Hallucinations

WSP:

Wasco State Prison

182