Failure to Notify Physician of Resident's Suicidal Ideation
Penalty
Summary
Facility staff failed to notify a resident's physician after the resident expressed suicidal ideation. The resident, who had a history of generalized anxiety disorder and suicidal ideations, was overheard by staff saying on the phone that they did not know if they wanted to live anymore. The staff member reported this to the charge nurse, who then spoke with the resident and suggested hospitalization for emotional support. However, there was no documentation that the resident's physician or responsible party was notified of the incident, as required by facility policy. Further review of the resident's electronic health record revealed the absence of a care plan and no documentation of the incident or any notifications made. Interviews with the LPN and DON confirmed that the physician was not notified, and the incident was not documented at the time. The LPN stated they did not notify the DON or physician because they believed the resident was okay after their conversation. The DON and administrator both indicated that they would expect the physician to be notified in such situations, but this did not occur.