Failure to Assess and Monitor Resident with Suicidal Ideation and Depression
Penalty
Summary
The facility failed to ensure that a resident with a history of mental disorder and psychosocial adjustment difficulties received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. The resident, who had diagnoses including bipolar 2 disorder, depression, and alcohol dependence, exhibited fluctuating symptoms of depression and suicidal ideation as documented in multiple MDS assessments. Despite these documented symptoms, the facility did not consistently assess or monitor the resident for worsening signs of depression or suicidal ideation, nor did they provide timely behavioral health services as ordered by the physician. The resident expressed feelings of frustration, lack of autonomy, and dissatisfaction with his living situation and care, including issues with daily routines and access to preferred food and services. He reported feeling bad about himself, being a failure, and having thoughts of being better off dead or hurting himself during several assessment periods. However, there was no evidence that the facility followed up on these expressions with appropriate assessments, documentation, or interventions. The last documented psychotherapy visit was over a year prior, and although counseling was ordered, the resident was not seen by counseling services as required. Interviews with facility staff revealed a lack of awareness and follow-through regarding the resident's mental health needs. Staff members, including the social services director and MDS coordinator, acknowledged that they did not document or act upon high PHQ-9 scores or expressions of suicidal ideation. There was also a significant gap in behavioral health services due to provider absence, and no alternative arrangements were made for the resident to receive necessary mental health care. The facility's failure to identify, monitor, and address the resident's mental health symptoms and suicidal ideation constituted a deficiency in providing appropriate treatment and services.