Failure to Implement Timely Behavioral Health Safety Interventions
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of bipolar disorder, dissociative disorder, and previous suicidal ideation with self-harm. Despite documented behaviors such as agitation, verbal reactivity, and frequent calls to emergency services, the facility did not implement or update a safety plan in the resident's care plan after multiple hospitalizations for suicidal ideation and self-harm incidents. The resident experienced three separate incidents of suicidal ideation and two attempts to cut her wrists with scissors over a period of less than two months, yet crisis/safety plan interventions were not timely incorporated into her care plan following her returns from the hospital. The care plan in place addressed some behavioral concerns but failed to include specific safety interventions recommended after hospital discharges, such as identifying warning signs, internal coping strategies, and environmental safety measures like removing access to sharp objects. There was also a lack of documentation of follow-up with behavioral health providers after hospitalizations, and suicide risk assessments were not completed prior to the resident's suicide attempts. Monitoring interventions, such as frequent 15-minute checks, were inconsistently documented, and the care plan did not reflect changes in monitoring tools, such as the discontinuation of a wanderguard or camera, nor did it specify alternative safety measures. Staff interviews revealed uncertainty about the implementation of safety interventions and communication with behavioral health providers. The facility's own policy required individualized behavioral health services and timely updates to care plans based on comprehensive assessments, but these were not followed. The lack of timely coordination and implementation of person-centered behavioral and safety interventions resulted in repeated incidents of suicidal ideation and self-harm for the resident.