Failure to Complete Physician-Ordered 15-Minute Checks for Resident with Suicidal Ideation
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to follow physician orders for 15-minute checks for a resident who had been placed on this monitoring protocol due to suicidal ideation. The clinical record indicated that the 15-minute checks were to be documented on a paper sheet from 3/27/25 to 4/16/25. However, review of the documentation revealed multiple missing checks on several dates within this period, with the number of missed checks ranging from 7 to 75 on specific days. This information was confirmed with the Director of Nursing.