63N-1.0098. Serious Suicide Attempt or Serious Self-Inflicted Injury Review and Mortality Review

(1) The facility superintendent or program director shall establish a review process for every Suicide Attempt or Serious Self-Inflicted Injury requiring hospitalization or medical attention and a mortality review for a completed suicide. (2) The serious Suicide Attempt or Serious Self-Inflicted Injury review process and mortality review process shall be multidisciplinary, involving administrative, direct care, mental health and medical personnel and include a critical inquiry of the following: (a) The circumstances surrounding the incident; (b) Facility procedures relevant to the incident; (c) All relevant training received by involved staff; (d) Pertinent medical and mental health services involving the victim; (e) Possible precipitating factors leading to the Suicide Attempt, Serious Self-Inflicted Injury or completed suicide; (f) Recommendations, if any, for changes in policy, training, physical plant, medical or mental health services and/or operational procedures shall be made in writing.