Health Care Department Operations Manual

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Chapter 3 – Health Care Operations

Article 1 – Complete Care Model

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3.1.19 Next of Kin Notification for Death, Serious Illness, or Serious Injury

  • Policy

    • California Department of Corrections and Rehabilitation (CDCR), California Correctional Health Care Services (CCHCS) shall comply with all applicable state laws and regulations for notifying next of kin (NOK) for death, serious illness, serious injury, including incidents of serious injury due to self-harm, suicide attempts, or accidents.

  • Purpose

    • To standardize a statewide process for the initial notification to NOK and for providing necessary medical and mental health information related to the patient’s death, serious illness, or serious injury including incidents of serious injury due to self-harm, suicide attempts, or accidents.

  • Responsibility

    • Statewide

      • CCHCS and CDCR departmental leadership at all levels of the organization, within the scope of their authority, shall ensure administrative, custodial, and clinical systems are in place and appropriate tools, training, technical assistance, and levels of resources are available to ensure this policy is successfully maintained.

    • Regional

      • Regional Health Care Executives are responsible to maintain this policy at the subset of institutions within an assigned region.

    • Institutional

      • The Warden, or designee, is responsible for the initial NOK notification for death, serious illness, or serious injury including incidents of serious injury due to self-harm, suicide attempts, or accidents.

      • The Chief Executive Officer (CEO) is responsible for the local monitoring and evaluation of this policy at their assigned institution.

  • Procedure

    • The Primary Care Provider (PCP) or the Provider on-Call (POC) shall inform the Chief Medical Executive (CME), or designee, as soon as practicable that a patient has a serious illness, serious injury, or has been declared deceased. For serious injury caused by a probable self-harm or suicide, the Triage and Treatment Area Registered Nurse shall inform the Chief of Mental Health (CMH), or designee, if indicated.

    • The CME, or designee, shall conduct a review of relevant patient health information to determine if the patient has a serious illness, or injury, or to determine possible etiology of death if the patient has been declared deceased. The CMH, or designee, shall conduct a review of relevant patient health information to determine if the patient committed serious self-harm or suicide attempts requiring hospital admission or resulting in death.

    • After determining that the patient met the criteria for a serious illness or injury, or has been declared deceased the CME/CMH, or designee, shall inform the Warden, or designee as soon as practicable, to initiate the NOK notification. For serious injury or death caused by a probable self-harm or suicide attempt, the CMH, or designee, shall have a follow-up call to the NOK if they are listed on the CDCR 7385, Authorization for Release of Protected Health Information within 72 hours from the initial call, to confirm that the serious injury or death is due to self-harm or suicide attempt.

    • The Warden, or designee, shall:

      • Contact the NOK as identified in the Electronic Records Management System (ERMS) within 24 hours after the patient’s condition is deemed to be serious by a health care provider or the patient has been declared deceased.

      • Document and track the initial NOK notification.

      • Provide the patient’s NOK, or authorized agent, the Institutional Patient Health Care Inquiry (PHCI) Hotline phone number to call for additional information related to the patient’s medical and or mental health condition.

    • All calls received by the Institutional PHCI Hotline shall follow procedures and operating standards pursuant to the CCHCS Health Care Department Operations Manual (HCDOM), Section 2.3.15, Headquarters Patient Health Care Inquiry Response.

    • If the patient lacks the capacity to make their own health care decisions, and a health care decision needs to be made, the primary source of information for a health care proxy is the advance directive or the CDCR 7465, Physician Order for Life Sustaining Treatment. The person listed on the advance directive or the CDCR 7465 shall receive relevant health care information regardless of whether they are listed on the CDCR 7385. If the patient does not have an advance directive, or CDCR 7465, the NOK listed in ERMS shall be notified.

    • Health care information shall only be provided to or shared with the person or agent listed on the CDCR 7385, unless as stated above in (d)(6).

    • In cases of serious illness or serious injury, health care information shall not be released to the NOK if the patient did not list the NOK on the CDCR 7385. However, if the patient is declared deceased, an estate executor, administrator, or any other person authorized by state law shall act as the representative of the decedent and shall have access to the decedent’s protected health information.

  • Training Requirements

    • The CEO shall ensure that all applicable health care staff complete the Next of Kin Notification for Death, Serious Illness, or Serious Injury training on the Learning Management System.

  • References

    • Title 45 Federal Code of Regulations, Section 164.502(g)(4), Uses and Disclosures of Protected Health Information: General Rules

    • California Penal Code, Part 3, Title 1, Chapter 2, Article 1, 2064.1

    • California Penal Code Part 3, Title 7, Chapter1, Section 5022

    • California Code of Regulations Title 15, Division 3, Chapter 2, Subchapter 3, Article 13, Section 3999.417

    • California Department Operations Manual, Chapter 5, Article 7, Section 51070.1 and 50170.10

    • California Correctional Health Care Services Health Care Department Operations Manual, Section 2.3.4, Release of Information

    • California Correctional Health Care Services Health Care Department Operations Manual, Section 2.3.15, Headquarters Patient Health Care Inquiry Response

  • Revision History

    • Effective: 06/2022