Failure to Develop and Implement Comprehensive Care Plan for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with specific interventions to ensure the psychosocial well-being and safety of a resident with multiple mental health diagnoses, including schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety disorder, and a history of suicidal ideation and attempts. Despite the resident being cognitively intact and having a care plan that included interventions such as 15-minute safety checks, use of only plastic silverware, placement in a room with a roommate, and removal of potentially harmful items, there were lapses in the execution and specificity of these interventions. Documentation revealed that the resident had recent incidents of self-harm, including drinking hand sanitizer and attempting to suffocate herself with a plastic bag. Observations showed that clear trash liners, which could pose a risk, were accessible in both the resident's and roommate's trash cans. Staff interviews indicated a lack of consistent understanding regarding the appropriateness of trash liners in the resident's environment. The facility's policy required comprehensive care plans with measurable objectives and timeframes, but the care plan for this resident did not adequately address all identified risks or ensure staff were fully informed and consistent in implementing interventions.