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F0742
D

Failure to Implement Suicide Precautions for Resident with Suicidal Ideation

Mifflin, Pennsylvania Survey Completed on 06-27-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement physician-ordered suicide precautions for a resident diagnosed with anxiety, major depressive disorder, and dementia with behavioral disturbances. The resident had expressed suicidal ideations, specifically stating an intent to kill herself by ripping her veins out and was observed pinching at the veins in her arms. In response, a physician ordered suicide precautions, including the removal of sharp objects from the resident's room and the use of a cordless call bell for 48 hours. Despite these orders, observations on two separate occasions revealed that the resident continued to have a corded call bell attached to her bed and sheets while she was in bed. Staff interviews confirmed awareness of the suicide precautions and the requirement for a cordless call bell, yet the corded call bell remained in use. The Nursing Home Administrator and Director of Nursing were informed of these concerns regarding the failure to follow suicide precaution protocols for the resident.

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