Failure to Supervise and Monitor Resident with Suicidal Ideation
Penalty
Summary
A deficiency occurred when facility staff failed to provide adequate supervision and follow physician orders for a resident with a history of suicidal ideation, depression, and psychoactive substance abuse. The resident had recently exhibited self-harm behavior by holding scissors to his neck and expressing suicidal thoughts, which led to a physician order for every 15-minute monitoring and the use of plastic utensils. The care plan and facility policy required close monitoring and documentation of the resident's status to prevent self-harm. Despite these orders and interventions, there was no documentation to show that the required 15-minute checks were performed on the day of the incident. Staff interviews confirmed that the monitoring form for the relevant time period was left blank, and the administrator could not provide evidence that the checks were completed or properly discontinued. Staff members, including CNAs and LNs, were either unaware of the resident's risk or could not confirm how the resident obtained a razor blade, which was used in the self-harm incident. As a result of the lack of supervision and failure to follow the monitoring protocol, the resident was able to obtain a razor blade, inflict multiple deep lacerations on his arms and legs, and required emergency medical intervention and hospitalization. The facility's own policy and job descriptions emphasized the importance of monitoring and documentation for residents at risk of self-harm, but these procedures were not followed, directly leading to the resident's injury.