Failure to Provide Behavioral Health Care After Resident's Suicidal Ideation
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary behavioral health care and services to a resident who verbalized suicidal ideation. The resident, who had a history of hemiplegia, hemiparesis, diabetes mellitus, a stage III pressure ulcer, muscle spasms, and muscle weakness, was assessed as having moderately impaired cognitive skills and was dependent on staff for several activities of daily living. The resident's PHQ-9 score indicated moderate depression, and the care plan identified a risk for mood problems, including depression and potential self-harm. Despite the resident's repeated verbalizations of wanting to die and refusal of medications and meals, staff did not consistently assess or monitor the resident's behavior following these statements. Documentation showed that the resident's expressions of suicidal ideation were not followed by appropriate monitoring or assessment, and there was no evidence of a psychiatric evaluation being conducted after these incidents. Staff interviews confirmed that the resident's behavior was not documented in progress notes, and key personnel, including the MDS nurse and social services director, were not informed of the resident's statements. Additionally, the care plan interventions for monitoring and reporting risk for self-harm were not implemented as required. The physician was notified of the resident's medication refusals and suicidal ideation, but there was no follow-up to ensure the resident's safety, such as one-on-one observation or immediate psychiatric assessment. Staff interviews revealed a lack of communication and follow-through, with some staff unaware of the resident's statements and others not receiving responses from medical providers. The facility's policy required comprehensive, interdisciplinary care for behavioral health needs, but this was not carried out in the resident's case.