Failure to Provide Immediate Behavioral Health Interventions for Residents Expressing Suicidal Ideation
Penalty
Summary
The facility failed to provide immediate and necessary behavioral health care and services for two residents who expressed suicidal ideation. One resident, with a diagnosis of depression and a recent significant weight loss, reported feeling suicidal to a nurse, but there was no evidence of one-on-one monitoring, removal of potentially harmful objects, or an updated care plan addressing suicidal ideation. Staff interviews revealed that after the resident expressed suicidal thoughts, the information was reported to the unit manager, but no further immediate safety measures were implemented, and the care plan did not reflect the resident's current mental health needs. Another resident, also diagnosed with depression and previously observed holding scissors to his wrist while expressing a desire to die, was later found with a skin tear on his wrist. Although the physician was notified and treatment was provided, there was no documentation that staff investigated the cause of the injury. The resident continued to express emotional instability and thoughts of self-harm, and staff responses were limited to reassurance and email notifications, without evidence of increased monitoring or environmental safety checks. The social services team was not consistently informed of the resident's behaviors, and the director of nursing was unaware of the ongoing issues. Observations showed that both residents had access to potentially harmful items in their rooms, such as gait belts, electrical cords, and plastic bags, despite their expressed suicidal ideation. Facility policy required staff to take suicide threats seriously, remain with the resident, and notify appropriate personnel, but these procedures were not consistently followed. The lack of immediate action and investigation into self-harm incidents demonstrated a failure to ensure resident safety and provide necessary behavioral health interventions.