Failure to Immediately Intervene for Suicidal Ideation and Behavioral Health Needs
Penalty
Summary
The facility failed to immediately intervene when a resident with a recent history of suicidal ideation and multiple suicide attempts expressed a desire to commit suicide. Despite the facility's policy requiring that residents expressing suicidal tendencies not be left unattended and that staff immediately notify a nurse, there was a significant delay in response. On one occasion, the resident was observed crying and stating a wish to kill themselves, but staff did not remain with the resident or promptly assess their condition. The environmental aide informed the nurse, who was on a phone call and did not immediately check on the resident. The resident remained alone, crying and expressing suicidal thoughts, for over fifteen minutes before a nurse arrived and eventually arranged for hospital transport. The resident had a documented history of depression, anxiety, schizophrenia, and previous suicide attempts, including overdosing and attempting to strangle themselves. The care plan indicated the need for close monitoring and immediate intervention if the resident posed a threat to themselves. However, documentation showed gaps in psychosocial follow-up and a lack of consistent behavioral health services. Staff interviews revealed uncertainty about the frequency and type of behavioral health services provided, and the social services designee admitted to not documenting therapy sessions and being unsure of their own qualifications to provide therapy or assess safety for discontinuing one-on-one monitoring. Additionally, the facility failed to address the behavioral needs of another resident who became agitated and left a secured unit. Staff did not offer alternative activities or explanations, and the resident was left pacing and expressing agitation after being redirected back to the unit. The care plan for this resident identified them as an elopement risk and required interventions to distract and redirect, but these were not implemented during the observed incident. Interviews with the administrator and DON confirmed that staff did not follow expected procedures for managing agitation and supervision.