Failure to Revise Care Plan After Repeated Self-Harm Incidents
Penalty
Summary
A resident with a history of suicidal ideations, major depressive disorder, unspecified dementia, and delusional disorders was admitted to the facility. The resident's care plan included interventions such as providing plastic utensils, frequent staff rounding, weekly psychotherapy, and 1:1 monitoring during meal times. Despite these interventions, the resident was able to access metal utensils on multiple occasions and attempted self-harm, resulting in transfers to the hospital emergency department for evaluation. The care plan was updated after each incident, including the addition of every 15-minute head checks for 72 hours, but the resident continued to obtain items that could be used for self-injury. The facility failed to ensure that the comprehensive care plan was reviewed and revised for effectiveness when the resident continued to gain access to objects used for self-harm. Although some interventions were implemented, there were no additional care plan measures developed or put in place to specifically prevent the resident from obtaining potentially harmful items. Interviews confirmed that the resident was able to access silverware on multiple occasions despite existing care plan interventions.