Failure to Provide Treatment and Monitoring for Resident with Mental Health Crisis
Summary
A resident with diagnoses of depression, anxiety, and borderline personality disorder was identified as being a danger to self and others (DTSO) after verbalizing intentions to harm self and others. Despite a physician's order for transfer to a general acute care hospital (GACH) and recommendations for psychiatric and psychological consultations, the resident refused these interventions. The facility failed to implement 1:1 sitter observation, did not monitor or document the resident's behavior after being identified as DTSO, and did not develop or implement a care plan to address the resident's refusal of transfer or psychiatric consultation. There was no evidence in the medical record that the facility monitored the resident's behavior or provided additional interventions after the resident refused psychiatric consultation. Staff interviews confirmed that no hourly monitoring, documentation, or care planning was initiated following the resident's refusal of transfer and ongoing verbalizations of self-harm or harm to others. The interdisciplinary care team did not meet to address the situation, and there was no documentation of behavioral observations or safety interventions in the resident's chart during the period of risk. As a result of these failures, the resident was later found unresponsive in their room with opened prescription medication containers not dispensed by the facility. The resident was transferred to the hospital via emergency services, where toxicology confirmed an intentional overdose of tricyclic antidepressants. The resident required intubation and admission to the intensive care unit. The facility's lack of assessment, supervision, monitoring, and care planning for a resident identified as DTSO directly preceded this critical incident.
Removal Plan
- The charge nurse will immediately notify the physician if the resident refused to go to the hospital, refusal of care and treatment for psychiatry and psychologist.
- If a resident has an order to be transferred to the hospital for further evaluation who exhibits any behavior, and refused to be transferred to the hospital licensed nurse will immediately notify MD.
- The Director of Social Services completed a Psychosocial Assessment of identified residents who has a diagnosis of depression, reviewed and updated Care Plan as necessary.
- Licensed staff were instructed to document behavioral observations in the monitoring log such as DTSO every hour and notify the nurse or RN supervisor and/or designee.
- The Medical records Director generated an audit of all residents with diagnoses including anxiety disorder, borderline personality disorder, and Depression; and provided the list to the Assistant Director of Nursing (DON) and the Administrator for further review and analysis.
- The Director of Social Services completed a psychosocial assessment of all residents with a diagnosis of depression to identify residents who may be DTSO and no other residents were identified at risk of harming themselves or others.
- Situation, Background, Assessment, and Recommendation (SBAR) / Change in Condition (COC) was implemented, and in-service was conducted by Assistant DON and Clinical Consultant to licensed nurses that the facility promptly notifies the resident, the resident's physician and the resident's representative of any changes in the resident's medical/mental condition and/or status.
- 72-hour monitoring including mood/behavioral changes, interactions with staff and peers, response to redirection, and safety observations will be implemented for the resident/s. The Assistant DON and clinical consultant conducted an in-service to licensed nurses to include mood/behavioral changes, interactions with staff and peers, response to redirection, and safety observations.
- The care plan was reviewed and updated for identified residents who has a diagnosis of depression. Assistant DON and clinical consultant provided in-service to license nurses regarding Care plan documentation for residents that addressed a psychiatric crisis and refusal to comply with the physician's recommendation for hospital transfer for resident's safety.
- The Administrator conducted 1:1 in-service to SSD regarding Care plan documentation for residents that addressed a psychiatric crisis and refusal to comply with the physician's recommendation for hospital transfer to ensure resident's safety.
- Crisis Intervention Plan included: Provide safe and clean environment; Visual check and document monitoring of resident behavior every hour for resident safety; Administer medication as ordered; Diet as ordered; Encourage to verbalize feelings; Always approach in calm and friendly manner and unhurriedly; To ensure all needs are met; Provide emotional support; Maintain comfort and dignity; To call doctor of medicine (M.D) for any noted change of condition.
- Social Services will re-evaluate and update initial psychosocial assessment of the resident when a resident refused for psychiatric consult and licensed nurse will inform MD.
- Social services will make daily visits to re-engage the resident and residents who are identified with diagnosis of depression, anxiety and borderline personality disorder and documented in the progress notes and provide resident's education on the importance of psychiatric evaluation.
- Behavioral and Crisis intervention care plan will be implemented to reflect ongoing risk for harm to self and others. Interventions included: PRN and scheduled psychiatric medication management; Behavior tracking and psychiatric consultation follow-up; Staff re-education on management of residents with psychosocial adjustment difficulties; Development of a crisis intervention care plan to Resident 1's behavior that triggers and de-escalation techniques.
- The ADON and Clinical consultant conducted in-service licensed nurses regarding policy and procedure SBAR/COC with emphasis on immediately reporting resident for any change in the resident medical/mental condition.
- Licensed staff in-services will continue until compliance is met.
- All licensed nurses and social services staff were in-serviced by Administrator, ADON and Clinical consultant regarding the existing policies and procedures: Charting and Documentation Policy for management of residents with psychiatric/psychologist who has a diagnosis of depression, anxiety, borderline personality disorder and danger to self and others; Requesting, Refusing and/or Discontinuing Care or Treatment; Initial Psychosocial Assessment, Intervention and Monitoring Policy and Implementation of Crisis Intervention Policy.
- The Director of Nursing (DON) and/or ADON will audit all residents with behavioral risks for residents who have diagnosis of depression, anxiety, borderline personality disorder and danger to self and others weekly x 4 weeks, then monthly x 3 months.
- All refusals of psychiatric care or hospital transfers will be reviewed by the IDT within 24 hours of occurrence and to notify primary care physician.
- Results of audits and compliance monitoring will be reported by the DON and/or ADON monthly to the Quality Assurance and Performance Improvement (QAPI) committee.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Address Behavioral and Psychosocial Needs: A resident with ESRD and a traumatic amputation had verbal outbursts, cursing, and derogatory language toward staff, but was not referred for behavioral health or grief counseling after his son’s death. The resident missed dialysis treatments because of behavior and a funeral conflict, and the NP, SSD, and DON confirmed there was no notification to the provider or referral to in-facility psychiatric services despite available behavioral health support.
Failure to assess and monitor suicidal ideation: A resident admitted with a painful hip fracture and no prior MH dx voiced that he would be better off dead on a PHQ-9 and later told therapy he would kill himself if he had the means. The SW documented the statements but did not notify admin, the DON, or the MD, and no MH referral or suicide precautions were implemented. Staff across disciplines were not informed of the prior suicidal comments, and the resident was later found unresponsive in bed with a cord around his neck; EMS determined the event was intentional self-harm and the death certificate listed suicide.
A resident with depression, cognitive decline, and severe cognitive impairment had an ordered psychology/psychiatry consult that was not completed for months despite ongoing agitation, refusal of care, yelling at staff, and other disruptive behaviors. The DON acknowledged the consult should have been arranged and completed, but the facility’s psych provider was on maternity leave and the covering provider did not appear, so no service was provided.
A resident made suicidal statements and later threatened to commit suicide, but the clinical record lacked evidence of a self-harm/suicide assessment or provider notification. The care plan was also not updated to include triggers, goals, or interventions for suicidal ideation, and facility leaders confirmed the gaps in the record.
Failure to identify resident-specific behavioral triggers: A resident with anxiety, depression, irritability, and trauma history was observed tearful and distressed while discussing multiple family losses and conflict with other residents and staff. Records showed psych notes about holiday-related distress, ruminating, accusations of poisoning, and mild paranoia, but the care plan did not include key triggers such as holidays/Thanksgiving, lab draws, grief, or paranoia, and did not list relaxation as an intervention.
Failure to address depression and psychosocial needs: A resident with dementia, depressive disorder, and behavioral issues had PHQ-9 scores showing mild to moderate depression, but the record did not document follow-up for the increased score or consistent implementation of behavioral health recommendations. The resident often isolated in his room, declined activities, and had care plan interventions for depression and verbal aggression that were not consistently reflected in the chart or carried out as documented.
Failure to Address Behavioral and Psychosocial Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services to address known psychosocial concerns for one resident who had verbal outbursts, cursed, and used derogatory language toward staff. The resident was cognitively intact with a BIMS score of 15 and had diagnoses including end stage renal disease and a traumatic amputation of two or more right lesser toes. The Quarterly MDS identified verbal behavioral symptoms directed toward others, but the resident was not referred for in-facility psychiatric services or grief counseling despite the facility’s available behavioral health services. Record review and interviews showed that the resident missed dialysis treatments because of behavior and because one make-up dialysis appointment conflicted with his son’s funeral. The resident representative stated she was concerned about the missed medical and dialysis appointments and was not aware of any grief counseling offered after the death of the resident’s son. The DON confirmed that the resident missed dialysis because of behavior and that the resident also missed a dialysis appointment on the day of the funeral. She stated that the resident had shown a change in behavior during his stay and that staff received the brunt of his behavior. The NP stated she was not notified that the resident missed dialysis treatments and that there was no documentation that the covering NP was notified. The SSD confirmed awareness of the resident’s verbal outbursts but had not notified the primary healthcare provider and had not referred the resident to behavioral health services. The DON also confirmed that no referral was made to behavioral health contract services and that the resident’s doctor or NP was not notified that his behavior interfered with his scheduled dialysis treatments.
Failure to assess and monitor suicidal ideation
Penalty
Summary
The facility failed to ensure a resident who had voiced suicidal ideations received a mental health evaluation, monitoring, and suicide precautions after multiple staff members documented or heard statements that he would be better off dead or would kill himself if he had the means. The resident was admitted after a fall with a non-operable left hip fracture, acute pain, and moderate protein-calorie malnutrition, and he had no mental health diagnoses on admission. His baseline care plan did not include goals or interventions for depression or mental health. He also had a history of opioid and fentanyl exposure and a blood alcohol level of 15 at the hospital, and the Medical Director later documented a long-term depression history and alcohol use. On the resident’s depression screening, the Social Worker documented that the resident said he would be better off dead because of the amount of pain he was experiencing, and the PHQ-9 score was 10, indicating moderate depression. The Social Worker did not notify administration, the Medical Director, or nursing, did not begin monitoring, and did not make a mental health referral. Two days later, therapy staff documented that the resident stated he would kill himself if he had the means. Therapy staff reported the statement to the Therapy Manager and a nurse, but the information was not escalated to administration, the Medical Director, or other leadership at that time. The Medical Director later saw the resident and documented that he was miserable, upset, distraught, and in severe pain, but the depression was deferred until pain was controlled. The resident’s suicidal statements were not communicated consistently across disciplines, and staff interviews showed that multiple nurses and aides were unaware of the earlier suicidal comments. The Social Worker later met with the resident after administration learned of the statement and reported that he was no longer suicidal, but no formal assessment or psychiatric referral was completed. On the evening of the incident, the resident was described as irritated and wanting to be left alone; he also asked for his phone to be unplugged and did not want to talk with family. Later that night, he was found unresponsive in bed with the bed control cord wrapped tightly around his neck, without breathing or a pulse. EMS determined the cardiac arrest was associated with intentional self-harm by hanging, and the death certificate listed the manner of death as suicide by self-strangulation with the bed control cord.
Delayed Psychology/Psychiatry Consult for Resident With Behavioral Symptoms
Penalty
Summary
The facility failed to ensure timely completion of a physician-ordered psychology/psychiatry consult for one resident with depression, age-related cognitive decline, and cognitive communication deficit. The resident’s MDS dated 2/25/26 indicated severe cognitive impairment and problematic behaviors directed toward others, including threatening, yelling at, or cursing at staff. An order dated 7/30/25 for a psychology/psychiatry consult with follow-up treatment as indicated was present in the order summary, but there was no evidence the consult was completed during the 11-month period reviewed. Facility progress notes documented ongoing behavioral and psychological concerns during that period, including increased evening agitation, multiple outbursts toward staff, fear of staff leaving the room, refusal of care, yelling and waving her hand aggressively at staff, calling police to complain that she was being held captive, and another episode of yelling during care. During interview, the resident stated one incident reported as abuse occurred because a CNA was rushing her. The DON stated the consult should have been arranged and completed and explained that the facility’s psychology/psychiatry provider had been on maternity leave and the covering provider failed to show up, resulting in no service being provided.
Failure to Assess and Care Plan Suicidal Ideation
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed suicidal ideation and signs of self-harm. The resident’s care plan meeting note dated 4/30/26 documented that the resident said he/she might as well commit suicide, but the clinical record lacked evidence that the resident was assessed for self-harm or suicide ideation, and there was no evidence that the provider was notified of the statement. A later provider communication note dated 5/10/26 documented increasing confusion and a threat to commit suicide that night. The resident’s most recent care plan update on 5/12/26 did not include goals or interventions related to suicidal ideation. During interviews on 6/2/26 and 6/3/26, the Market Clinical Lead, Social Service Director, Market Clinical Advisor, DON, and Market Clinical Lead confirmed there was no evidence the doctor had been notified, no evidence the resident had been assessed for self-harm/suicidal ideation, and no evidence the care plan had been updated to include triggers, goals, or interventions for threat of self-harm or suicide ideation.
Failure to Identify Resident-Specific Behavioral Triggers
Penalty
Summary
The facility failed to ensure behavioral triggers were identified and assessed for a resident with diagnoses including left side weakness due to a stroke, anxiety disorder, insomnia, irritability and anger, major depressive disorder, and unspecified affective mood disorder. The resident’s annual BIMS score was 15, indicating no cognitive loss. During observation and interview, the resident was tearful while discussing the deaths of their mother and brother, stated they felt alone, described multiple family losses and the deaths of three friends at the facility, and reported conflict with two other residents who antagonized them and accused them of receiving preferential treatment. The resident also reported distrust of staff, alleged that the Dietary Manager shared protected health information with other residents, stated the facility arranged an outside agency evaluation without permission, and alleged a staff member intentionally struck them with another resident’s wheelchair. Record review showed psychiatric notes documenting concern about holidays and the upcoming anniversary of the brother’s death, ruminating on past events, accusations that staff attempted to poison the resident, and mild paranoia related to state examinations and dietary restrictions. The care plan identified trauma related to the deaths of the resident’s father, mother, and brother, and identified triggers such as other residents being assisted before them and the presence of a specific resident, but it did not include holidays, especially Thanksgiving, lab draws, paranoia, grief, or relaxation as an intervention. The Social Service Director stated the resident was paranoid at times and was aware the resident had been verbally abusive to a lab technician, but was not aware the resident blamed the hospital lab for their mother’s death.
Failure to Address Depression and Psychosocial Needs
Penalty
Summary
The facility failed to ensure a resident with diagnoses including dementia with behavioral disturbance and depressive disorder received appropriate treatment and services to support mental and psychosocial well-being. The resident’s MDS showed moderate cognitive impairment, verbal behaviors toward others, and depression identified through PHQ-9 screening. The resident also received an antidepressant and an antipsychotic medication, and the record showed no gradual dose reduction attempt or documentation that it was clinically contraindicated. Record review and observations showed the resident spent much of the day in his room with the lights off and blinds closed, often sat alone in the dining room, and told staff he did not like to participate in facility activities. The care plan identified depression, self-isolation, verbal aggression, and the need for psychosocial monitoring, emotional support, activities of interest, and behavioral interventions such as calm approach, positive reassurance, one-on-one interactions, and a quiet environment. A psychiatry note also recommended a more proactive approach to encouraging the resident to attend activities, such as telling him it was time to go rather than asking if he wanted to go, but this recommendation was not reflected in the electronic record. The resident’s PHQ-9 scores showed mild depression in September 2025, then moderate depression in December 2025 and again in March 2026, but the record did not show documentation addressing the increased score, follow-up, interventions, or services offered. Physician orders included monitoring for behaviors, isolation, side effects of psychotropic medications, and offering non-pharmacological interventions, but the record showed these interventions were not consistently implemented or documented as effective. Staff interviews confirmed the resident could become upset when approached in a way that suggested he was blamed for resident-to-resident altercations, and the administrator and social services director acknowledged they could not locate documentation showing why the PHQ-9 score increased or that the behavioral health recommendation had been incorporated into the care plan.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.