Failure to Provide Adequate Supervision and Suicide Prevention for Resident with Suicidal Ideation
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and implement appropriate interventions for a resident who expressed suicidal ideation. The resident, who had a history of major depressive disorder, anxiety, bipolar disorder, and previous suicide attempts, verbally expressed a desire to end her life and specifically asked staff if the facility had helium, stating she wanted to kill herself. Despite this clear expression of suicidal intent, the resident was only placed on 15-minute monitoring checks, and a room search for potentially harmful objects was not conducted. The resident subsequently attempted to cut her right wrist with a microblade razor between the 15-minute checks, resulting in superficial wounds. The resident's care plan did not address her major depressive disorder, suicidal thoughts, or self-harm risk, despite her psychiatric history and recent statements. Staff interviews revealed that the facility's policy at the time was to initiate 15-minute checks if a resident did not have a specific plan for self-harm, and 1:1 supervision only if a plan was present. However, the resident's statements and actions indicated a significant risk, and the lack of a room search allowed her access to a razor, which she used in her suicide attempt. Additionally, staff involved in the incident could not recall receiving training on updated suicide prevention policies, and documentation of such training was not available. Further interviews with staff and review of facility policies confirmed that the resident was not provided with 1:1 supervision or an immediate room search following her suicidal statements. The facility's suicide prevention policy required that residents expressing suicidal ideation not be left alone and receive 1:1 care until emergency psychiatric care could be arranged. The failure to follow these protocols, update the care plan, and ensure staff training contributed to the resident's opportunity to attempt self-harm while under the facility's care.