Failure to Provide One-to-One Sitter for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services by not implementing a care plan intervention for a resident diagnosed with depression and suicidal ideation. The resident had a documented order and care plan for one-to-one sitter supervision following statements expressing a desire to die and refusal of medication. Despite this, on the night in question, there was no sitter present in the resident's room, as confirmed by multiple staff interviews and direct observation. Nursing notes and staff interviews indicated that the assigned staff were not aware of the sitter requirement, and the unit was short-staffed, with no additional personnel assigned to provide the required supervision. The facility's own policy required immediate one-to-one supervision for residents expressing suicidal ideation, and staff were obligated to report such statements to supervisors. However, the LVN on duty did not inform the RN supervisor about the lack of a sitter, and the Director of Staff Development could not provide documentation of staff assignment for the required supervision period. The Director of Nursing was also unaware of why the sitter was not assigned, despite the active order. This failure to implement the care plan and follow facility policy resulted in the resident not receiving the necessary behavioral health services as required.