Failure to Implement Suicide Precautions and Conduct Thorough Fall Investigations
Penalty
Summary
The facility failed to conduct thorough fall investigations for one resident and did not implement suicide precautions for another resident who expressed suicidal ideation. In the case of the resident with suicidal ideation, staff were made aware that the resident was expressing thoughts of self-harm, including statements about wanting to kill himself and asking for a lawyer before doing so. Despite this, the LPN on duty did not initiate the facility's suicide precautions protocol, which required immediate assessment, one-to-one supervision, notification of the registered nurse supervisor and physician, and removal of potentially dangerous items from the resident's environment. As a result, the resident was left unsupervised in his room, where he was able to obtain a sharp plastic object and cut himself before staff intervened. The clinical record review showed that no orders for suicide precautions or one-to-one supervision were obtained or entered into the electronic health record in response to the resident's expressed suicidal ideation. Staff witness statements confirmed that the resident was not under constant supervision at the time of the self-injury, and that the required safety interventions were not put in place. The facility's policy on suicide precautions outlined specific steps to be taken when a resident exhibits suicidal behavior or ideation, but these were not followed by the staff involved. Additionally, the facility failed to conduct thorough fall investigations for another resident with a history of repeated falls and a recent fracture. Fall reports for this resident on two separate occasions did not include any staff witness statements, and the DON confirmed that she was unable to locate such statements. The facility's falls management policy required thorough assessment and documentation following a fall, but this was not completed as expected.