Failure to Prevent Self-Harm Incident
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision for a resident who was found with ligature marks around the neck. The incident involved a resident who had been admitted with diagnoses including spinal stenosis, atherosclerotic heart disease, and Type 2 diabetes. The resident had an intact cognition with a BIMS score of 15 out of 15 but was noted to be moderately depressed with a score of 10 on the Resident Mood Interview. Despite these indicators, there was no psychological assessment documented in the medical record. The incident report revealed that the resident had intentionally used the call bell cord, which had been disconnected from the wall, to attempt self-harm. On the morning of the incident, a CNA responded to the resident's call bell, which was ringing, and found the resident unresponsive with the call bell cord wrapped around their neck. The CNA untied the cord and called for help, after which the resident regained responsiveness. The Administrator was informed of the incident and noted that the call bell cord had been unplugged, which could occur inadvertently due to bed adjustments. However, the Administrator could not recall if the resident sustained any injuries, and no psychological assessment was completed prior to the incident, indicating a lack of adequate monitoring and supervision for the resident's mental health needs.
Plan Of Correction
1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 NJ Ex Order 26.4(b) (1) at the facility. The Assistant Director of Nursing/Facility Educator (ADON/FE) immediately conducted an audit of all residents who had physicians orders for a referral for psychology assessment to ensure the consult was completed. There were no untoward findings. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All residents with referrals for psychology consults have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. On 12/27/2024, The Assistant Director of Nursing/Facility Educator (ADON/FE) and the facility Administrator conducted in-service education to the psychology provider on the process for psychology consults. The practitioner has been advised of the implementation of a tracking form for all psych referrals to ensure compliance. The ADON/FE educated the psychology provider on the process of documenting refusal of referrals in the electronic medical record. The ADON/FE provided in-service education to all nurses on the implementation of a tracking form for all psychology referrals to ensure compliance. The ADON/FE provided in-service education to all staff on the process of keeping residents free from hazards and providing the necessary monitoring and supervision for those individuals who may have signs or symptoms of depression. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. The Director of Nursing or designee will conduct audits of the psychology referral book to ensure all referrals for psychology or psychiatry consults are completed timely and documented. Audits will be conducted daily x 5 days, then weekly x 4 weeks, then monthly x 3 months. The results of all audits will be provided monthly x 3 months to the facility's Administrator and the Quality Assurance Performance Improvement (QAPI) Committee for review and comment. The QAPI committee meets on a monthly basis. The QAPI Committee will review and determine the need for further audits.