Failure to Assess, Document, and Care Plan for Suicidal Ideation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a documented history of suicidal ideation. Upon readmission from an acute care hospital, the resident's prior episode of suicidal ideation, including a stated plan to overdose on medication, was not accurately assessed or documented by the Social Services Director (SSD) or the admitting licensed nurse. The resident's medical records from the hospital indicated recent suicidal thoughts, feelings of hopelessness, and a history of aggressive behavior, but this information was not incorporated into the facility's assessment or care planning process. The SSD conducted an interview with the resident after readmission and asked about current suicidal thoughts, to which the resident denied any intent. However, the SSD did not document this conversation or the resident's history of suicidal ideation in the Social Service History & Initial Assessment. The assessment form's section for history of suicidal ideation/gestures was left blank, and the SSD did not notify nursing staff or initiate an interdisciplinary team meeting as required by facility policy. The Director of Nursing (DON) confirmed that no assessment, care plan, or monitoring for suicidal ideation was completed for the resident, despite the documented history and recent hospital evaluation. Interviews with facility staff, including the DON, SSD, and a registered nurse, revealed a consensus that the lack of assessment, documentation, and care planning for suicidal ideation could result in potential or actual harm to the resident. Facility policies required assessment for suicidality upon admission, thorough documentation, and the development of a care plan with appropriate interventions for residents with a history of suicidal ideation. These steps were not followed, and the resident's risk factors were not addressed in the care plan or through ongoing monitoring.
Plan Of Correction
F 740 Behavioral Health Services 483.40 Resident 1 was discharged to acute hospital for evaluation of his aggressive behavior on 5/6/25. All residents in house census as of 5/16/25 were reviewed by the DON and RN/LVN supervisors. Review was initiated on 5/16/25 to ensure that residents with a history of suicidal ideations have been assessed, care planned, and monitored. Review was completed on 5/22/25. NO other residents were affected. Social services department and licensed nurses were in serviced by the DON on 5/15 and 5/19/25 regarding Behavioral Health Services; Social services and licensed nurses are to accurately assess and document suicidal ideation upon admission; develop a care plan, and monitor the suicidal ideation behavior. Every other month, licensed staff and Social services department will be given an in-service regarding Behavioral Health Services by the DON. RN/LVN supervisors will monitor compliance during weekly admissions review using the suicidal ideation admission review log to ensure that residents' suicidal ideations have been assessed upon admission, care planned, and behavior is being monitored. Any findings will be corrected immediately and will be given to the DON for follow-up. Any significant findings will be reported by the DON during the quarterly QA&A meetings for discussion and recommendation for 6 months.