Failure to Update Behavioral Health Care Plan and Communicate Suicidal Ideation
Penalty
Summary
The facility failed to complete a baseline care plan and provide ongoing behavioral health services for a resident admitted with depression who experienced suicidal ideations. After being sent to the hospital for evaluation due to suicidal ideations, the resident returned to the facility, and documentation indicated the resident was not at risk for imminent harm. However, the resident declined to complete a safety plan but agreed to a follow-up call with Mental Health, which was not documented as completed. Interviews with CNAs revealed they were unaware of the resident's recent suicidal ideations, as this information was not included in the Kardex or communicated during shift reports. A review of the care plan and Kardex showed no evidence of a mental health or suicidal ideation care plan or safety interventions. The interim DNS/RNCM was also unaware of the relevant after-visit summary and mental health notes in the chart and confirmed that the care plan and Kardex were not updated and the follow-up call to Mental Health had not occurred.