Failure to Prevent Access to Hazardous Utensils for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for a resident with a history of suicidal ideation and self-harm. Despite care plan interventions specifying the use of only plastic utensils and 1:1 staff supervision during meals, the resident was able to obtain metal forks on two separate occasions. On both occasions, the resident manipulated the metal forks, breaking off prongs and attempting to stab themselves, which resulted in transfers to the hospital emergency department for evaluation. Staff were unable to determine how or when the resident obtained the metal utensils, and the required supervision and monitoring were not effectively implemented. The resident had diagnoses including suicidal ideation, major depressive disorder, unspecified dementia, and delusional disorders, and was assessed as having moderate cognitive impairment. The care plan interventions were in place due to the resident's risk for self-harm, but staff failed to prevent access to hazardous items and did not consistently provide the required supervision. Documentation and investigation following the incidents were also incomplete, as acknowledged by the DON, who did not conduct a full written investigation after the second incident.