Failure to Address Suicidal Ideation in Resident with Mental Health Concerns
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with mental and psychosocial adjustment difficulties. Resident R23, who was admitted with diagnoses of bipolar disorder, PTSD, and anxiety, expressed suicidal ideations. Despite this, the facility did not complete a psychosocial assessment for the resident, as confirmed by the Social Services Director. Additionally, the resident's care plan did not include interventions for suicidal ideation, which was acknowledged by the RN Supervisor. The facility's policy on 'Trauma Informed Care' emphasizes the importance of identifying and addressing residents' emotional and social needs, particularly those with a history of trauma. However, in the case of Resident R23, the facility did not adhere to this policy. Although the nursing staff communicated with the physician and obtained new medication orders for the resident's anxiety, the lack of a comprehensive assessment and care plan interventions for the resident's suicidal ideations constituted a deficiency in meeting the resident's mental and psychosocial needs.
Plan Of Correction
1. Resident R23 has been discharged from the facility and unable to rectify. 2. Social Workers will be educated on the need to care plan residents with PTSD and suicidal ideation interventions by the DON/Designee as well as perform psychosocial assessments. 3. Initial audit will be performed for any resident who trigger for PTSD or suicidal ideations by the Director of Social Services. Audits then will be performed 3x a week times 2 weeks, 2x a week times 2 weeks, 1x a week times 2 weeks. 4. The monthly reviews will be submitted to the QAPI committee for review and approval.