Failure to Address Behavioral Health Needs for Resident with Suicide History
Penalty
Summary
The facility failed to ensure that behavioral health services were provided to meet the needs of a resident with a history of suicide and a family history of suicide. Upon admission, the nurse did not include the resident’s suicide history in the Care Plan, and staff were not trained to identify or respond to behavioral health needs for this resident. The resident had been admitted for rehabilitative services with diagnoses including major depressive disorder, anxiety disorder, and a personal history of suicidal behavior, as well as a recent intentional self-harm drug overdose. Despite this, the Care Plan and assessments did not adequately address the resident’s suicide risk, and staff were unaware of the resident’s prior suicide attempt. Observations and interviews revealed that the resident was independent, participated in activities, and did not display overt behavioral changes that would have alerted staff to an increased suicide risk. Staff, including nurses and CNAs, reported that they were not informed of the resident’s suicide history and did not receive specific instructions to monitor for suicidal ideation or behaviors. The resident’s medical records and progress notes documented ongoing pain, depression, and medication changes, including medications with known side effects of suicidal ideation, but these factors were not integrated into a comprehensive behavioral health plan. On the morning of the incident, the resident was found deceased in their room, having used a shoestring to hang themselves in the closet. Staff interviews confirmed that the resident’s history of suicide was not communicated or documented in a way that would have prompted increased monitoring or intervention. The facility’s assessment and care planning processes did not ensure that staff had the necessary information or training to address the behavioral health needs of residents with a history of suicide, resulting in a failure to provide appropriate care.