Failure to Ensure Safe Environment and Behavioral Health Services for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to ensure a safe environment and provide necessary behavioral health care and services for a resident with a history of suicidal ideation and multiple mental health diagnoses, including anxiety disorder, depression, PTSD, gender identity disorder, and borderline personality disorder. The resident had previously expressed suicidal thoughts, including specific plans and intent, which led to a hospital transfer. Upon return, the resident continued to express thoughts of self-harm and disclosed access to a razor in her room. Staff interviews revealed a lack of awareness and implementation of suicide precautions for the resident. Several CNAs and an LPN who worked with the resident were either unaware of any interventions in place or did not know of any specific precautions being used. The resident was able to access potentially dangerous items, such as disposable razors, inhalers, and a full sharps container in her room. The DON and other staff confirmed that these items should not have been unsecured and accessible to a resident with suicidal tendencies. Observations confirmed the presence of unsecured inhalers and a full sharps container in the resident's room, and staff acknowledged these were not appropriate. The facility's behavioral health policy emphasized person-centered care and safety, but staff actions and interviews demonstrated a failure to follow through with necessary interventions and environmental safety measures for a resident at risk for self-harm.