Failure to Follow Suicide Threat Protocol and Notify Appropriate Staff
Penalty
Summary
Facility staff failed to follow established policy and professional standards when a resident with a history of generalized anxiety disorder and suicidal ideations expressed suicidal thoughts. The resident was overheard by a staff member stating on the phone that they did not know if they wanted to live anymore. The staff member reported this to an LPN, who spoke with the resident, assessed for a suicide plan, and monitored the resident at intervals. However, the LPN did not notify the Director of Nursing (DON) or the resident's physician, as required by facility policy, and did not document the incident at the time it occurred. The resident's electronic health record lacked a care plan addressing suicidal ideation, and there was no documentation of the date and time of the incident, DON notification, or physician notification. Interviews with the LPN, DON, and administrator confirmed that the DON and physician were not notified of the resident's suicidal statements, and that the incident was not documented according to policy. The DON and administrator both stated they were unaware of the resident's suicidal ideations and would have expected to be notified and for the incident to be documented. The physician's office also confirmed there was no record of notification regarding the resident's suicidal comments or emotional distress. These failures resulted in the facility not meeting professional standards of quality for addressing suicide threats.