Failure to Provide Medically Related Social Services for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide medically related social services to support a resident with a known history of suicidal ideation, resulting in a lack of appropriate person-centered care to meet the resident's highest practical psychosocial well-being. The resident had a documented history of suicide attempts, including overdosing and attempting to strangle themselves, and was diagnosed with anxiety and schizophrenia. The care plan identified suicide risk and outlined interventions such as monitoring, notification of the physician and power of attorney, and redirection to activities. Despite these documented needs, there were significant lapses in the provision and documentation of social services and psychosocial support. After returning from multiple hospitalizations for suicide attempts, the resident did not receive consistent or documented social services follow-up. Progress notes showed gaps in psychosocial or social services documentation, with no entries between key incidents. The resident expressed ongoing distress, including crying, stating a desire to harm themselves, and reporting a lack of access to group or individual counseling. During an observation, the resident was found in bed, crying, and expressing suicidal ideation, but staff response was delayed and uncoordinated. The Social Services Designee present did not check on the resident and deferred to nursing staff, who also did not provide immediate support or intervention. Interviews with staff revealed that Social Services Designees were not qualified to provide medically related social services and had not received formal training in managing residents with suicidal ideation. The facility had been without a qualified social worker for several months, and outside behavioral health services were no longer available. Staff were unclear about the interventions in place for the resident and did not consistently document or provide the required psychosocial support, resulting in a failure to meet the resident's psychosocial needs as outlined in their care plan.