Failure to Implement Individualized Behavioral Health Plan for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to ensure and implement an individualized plan of care for a resident experiencing psychosocial adjustment difficulties, resulting in harm. The resident, who had diagnoses of depression and dementia and was cognitively intact, expressed frequent feelings of depression and hopelessness, as documented in the Minimum Data Set. Despite these symptoms, the resident's care plan did not address his depression diagnosis, and there was no documentation of a psychiatric evaluation being ordered in the physician's orders. The resident repeatedly voiced thoughts of self-harm and a desire to leave the facility, with specific statements about wanting to end his life if he had to remain in the facility. Progress notes revealed multiple instances where the resident expressed suicidal ideation and distress, including statements about self-harm and feeling like a burden. Staff documented removing potentially harmful objects from the resident's room and noted ongoing behavioral monitoring, but there was a lack of consistent documentation regarding physician notification and follow-up on self-harm statements. The physician stated that an order for a psychiatric evaluation was faxed to the facility, but the administrator and staff were unaware of this order, and it was not present in the resident's chart. The social worker did not interview the resident on the day of a self-harm statement due to being out of the facility, and no documentation was made by the social worker for that incident. Interviews with staff indicated inconsistent understanding and implementation of procedures for addressing self-harm statements. The assistant director of nursing and social worker described protocols for assessment and notification, but these were not consistently followed or documented. The resident continued to display signs of distress, including tearfulness, refusal of care, and statements of wanting to leave or harm himself, without evidence of a comprehensive, individualized behavioral health plan or timely psychiatric intervention.