Failure to Ensure Timely Behavioral Health Evaluation After Suicidal Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely behavioral psychiatric evaluation and intervention for a resident admitted with a history of suicidal ideation, self-injurious behavior, paranoia, and agitation. The resident experienced multiple episodes of suicidal behavior, including attempts to harm themselves with utensils, and was transferred to the hospital emergency department on several occasions. Despite these incidents, there was no documentation that behavioral psychiatric services evaluated the resident until 13 days after the most recent suicidal episode. Additionally, there was no evidence that the resident's care plan or medications were adjusted in response to these behaviors during this period. The facility's communication process between nursing staff and the behavioral health provider was insufficient, as the nurse practitioner was unaware of the specific suicidal behaviors and attempts involving utensils, despite initialing the behavioral log entries. The nurse practitioner stated that had she been informed of the previous suicidal behaviors, she would have adjusted the resident's plan of care and/or medications earlier. The Director of Nursing was also unaware that the nurse practitioner had not been fully informed of the resident's suicidal behaviors.