Failure to Monitor and Address Worsening Depression in Resident with History of Suicidal Ideation
Penalty
Summary
The facility failed to ensure that a resident with a history of mental disorders, including major depressive disorder, suicidal ideations, and previous suicide attempts, received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. The resident, who was moderately cognitively impaired, reported worsening depression due to declining health and loss of abilities, and had a documented history of multiple hospitalizations related to depression. Despite these risk factors, the care plan and physician's orders did not include specific monitoring for suicidal ideations, nor did they incorporate resident-specific triggers and non-pharmacological interests identified in the Level II PASRR evaluation. Behavior monitoring orders were in place for increased sleep, decreased appetite, and verbalizations of sadness, but there was no documentation of behaviors despite the resident consistently sleeping 10-11.5 hours per day and expressing symptoms of depression during assessments. Progress notes indicated the resident reported feeling more depressed and hopeless, with PHQ-9 scores reflecting mild depression and symptoms such as decreased appetite and increased sleep. However, there was no evidence that staff followed up on these findings or increased monitoring for worsening depression or suicidal ideation. Interviews with staff revealed a lack of awareness regarding the resident's history of depression and suicidal ideations. Certified nurse aides and a registered nurse were unaware of the resident's mental health history, and the social services director did not recall the resident's identified triggers from the PASRR. The director of nursing was also unaware of the resident's history and acknowledged that monitoring for resident-specific signs and symptoms of depression was not being conducted as required.