Failure to Document and Monitor After Suicidal Ideation
Penalty
Summary
The facility failed to thoroughly document and monitor a resident after she verbalized suicidal ideation. According to the facility's policies, any staff member who becomes aware of a resident's intent to inflict self-harm is required to report the behavior to the Nursing Supervisor without delay, and the charge nurse or Nurse Supervisor must immediately assess the situation and determine necessary interventions. In this case, a resident with diagnoses including metabolic encephalopathy, anxiety, and major depressive disorder expressed suicidal ideation, stating she wanted to die by a specific date and did not want to live anymore. The psychiatric nurse practitioner, via telehealth, ordered the resident to be sent to the emergency room for evaluation, but there was no documentation of a physical or behavioral assessment, vital signs, or details of what the resident said to prompt the transfer. The nurse's notes only indicated the resident was sent to the hospital for being suicidal and later returned after being declared not suicidal, with no further documentation of assessments or follow-up. Additionally, the resident's care plan was not updated to reflect the suicidal ideation or to include new interventions or increased monitoring. The facility's documentation policy requires alert charting for incidents or changes in condition for at least 72 hours or until stable, but this was not completed. The Director of Nursing confirmed that follow-up alert charting should have been done and acknowledged the documentation was very poor in this case. The lack of thorough documentation and monitoring after the resident's expression of suicidal ideation constitutes the deficiency identified by the surveyors.