Segregated Inmates

E-11 Nursing Assessment Protocols (important)

Nursing assessment protocols are appropriate to the level of skill and preparation of the nursing personnel who will carry them out, and comply with the relevant state practice acts. Standing orders may be used only for preventive medicine practices. — 2008 Standards for Health Services for jails and prisons

Segregated inmates are those who are isolated from the general population and who receive services and activities apart from others. Whether you call it administrative segregation, protective custody, or disciplinary segregation, standard G02 Segregated Inmates is about the conditions of living and confinement, not the reason for the segregation or what the area is called.

First, let’s define the degrees of isolation as set forth in this standard’s compliance indicators.

Solitary Confinement (also referred to as isolation) refers to situations of extreme segregation where an incarcerated person is isolated and encounters other people (staff or incarcerated) fewer than three times a day. Compliance indicator 2a addresses this category.

The lesser degree of isolation, usually referrred to as segregation, refers to those who are isolated from the general population and who receive services and activities apart from others.

In supermax, lockdown facilities, or tiers, all individuals are in a segregated status and, therefore, all should be monitored under the auspices of this standard.

Review and Monitoring

The intent of the standard is to ensure that those placed in segregation maintain their medical and mental health while physically and socially isolated from the rest of the population. To ensure this, appropriate monitoring and health record review procedures should be in place.

The first step is the health record review. Compliance indicator 1 states: “Upon notification that an inmate has been placed in segregation, a qualified health care professional reviews the health record. If medical, dental, or mental health needs require accomodation, custody staff are notified and the review and notification, if applicable, are documented in the health record.”

Custody and health staff should have an effective system to communicate when someone is about to be, or has just been, placed in segregation. It is important for health staff to quickly determine whether there are contraindications or necessary accommodations to the segregation to minimize the risk of adversely affecting health. Documentation of this review (in the health record) prior to, or soon after, the placement is vital. NCCHC recommends that the responsible health authority be involved in the development of segregation policies and procedures so that appropriate accommodations for health conditions can be addressed.

Due to the complex conditions of segregation, health staff should review the health status of their patients prior to their placement into segregation, or upon such placement, to ensure continuity of care and services. Take care when reviewing health records of inmates with serious mental illnesses to assess the risk of exacerbation of the mental illness. Medical staff reviewing the record should notify mental health staff when the inmate is currently under the care of mental health services.

Next, frequent monitoring based on the degree of isolation should be initiated. Individuals under extreme isolation/solitary confinement should be monitored daily by medical staff and at least once a week by mental health staff (category 2a). Segregated individuals who have limited contact with others should be monitored three days a week by medical or mental health staff (category 2b).

The quality of the health round in segregation is key. Checks by health staff ensure that each individual has the opportunity to request care for medical, dental or mental health problems. These individual visits also enable health staff to ascertain general medical and mental health status. Those in segregation often experience irritability, anxiety or a dysphoric mood within weeks of placement in social isolation. Special attention should always be given to vulnerable populations, such as adolescents and the mentally ill. Due to the possibility of injury and depression during isolation, the evaluations by health staff should include notation of bruises or other trauma markings, comments regarding attitude and outlook (particularly as they might relate to suicidal ideation) and any health complaints.

Individuals with serious mental illness often experience an exacerbation of their underlying illness when segregated. NCCHC recommends that the health rounds on patients with serious mental illness in segregation take place at the beginning, middle and end of each week to decrease the likelihood of problems during weekend hours.

Simply initialing a housing roster upon entering the unit is not enough. Segregation rounds should be documented on individual logs or cell cards (and when filled should be filed in the health record) or in the health record, and include date and time of contact and the signature or initials of the health staff member making the rounds (compliance indicator 3). Significant findings should be documented in the health record (compliance indicator 4).

Health staff should note every time they make rounds, whether or not there is a health-related interaction or observation. However, necessary clinical encounters should not take place cellside but in an appropriate clinical setting and noted in the patient’s health record. When health care is requested, arrangements should be made for triage, examination and treatment in an appropriate clinical setting. Note that the segregation rounds are required in addition to whatever mechanism is in place for incarcerated individuals to request health services daily (see E-07 Nonemergency Health Care Requests and Services).