Failure to Update Care Plan After Resident's Suicide Attempt
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident following a significant mental health event. The resident, who had a history of major depressive disorder, anxiety, mood disorders, and previous suicide attempts, expressed suicidal ideation by asking staff for helium to end her life. Despite this clear expression of intent, the care plan was not updated to address suicide prevention or self-harm after the incident. The existing care plan only included general interventions related to antidepressant medication and monitoring for risk of harm, but did not specifically address the acute suicidal ideation or the subsequent self-harm event. On the day of the incident, the resident repeatedly asked for helium and stated her desire to kill herself due to family issues and feelings of hopelessness. Staff placed her on 15-minute checks as per facility policy at the time, but did not conduct a room sweep for potentially dangerous objects. During one of these checks, a nurse found the resident had cut her wrist with a microblade razor, which she had obtained independently. The staff intervened, provided first aid, and removed additional sharp objects from the room. The resident was then placed on one-on-one supervision and later transferred to the hospital for evaluation. Interviews with staff revealed gaps in training and awareness regarding suicide prevention protocols and care plan updates. The Director of Nursing, social worker, and other staff members acknowledged that the care plan should have been updated to reflect the resident's behaviors and risk for self-harm following the incident. Documentation showed that the interdisciplinary team did not revise the care plan or document a team meeting to address the resident's change in status, as required by facility policy. This failure to update the care plan after a significant change in the resident's condition constituted the deficiency identified by surveyors.
Removal Plan
- Resident #1's care plan was updated to reflect resident centered behavioral health status, including the initiation of a psychiatric virtual visit and ongoing behavioral observations.
- A 100% audit of current residents using the PHQ-9 screening tool began.
- Care plans are being updated, if warranted by the PHQ-9 screening tool, to reflect PHQ-9 results and ensure individualized, resident-centered care.
- Nursing administration staff received in-service training on care plan update protocols, provided by the regional compliance nurse.
- An ad-hoc QAPI meeting was held with the Medical Director, Administrator, Director of Nursing, and the interdisciplinary team to evaluate current systems related to care planning and suicide prevention. Local ombudsmen notified.
- QAPI will continue to review care plan compliance and quality monthly.
- The Director of Nursing or designee will monitor the 24-hour report (generated through Point Click Care based on progress notes entered into the residents chart) and PHQ-9 completion daily for any depression or suicidal thoughts and care plans will be updated as needed.
- Any discrepancies will be addressed immediately and reviewed during weekly clinical stand-ups and monthly QAPI meetings.