Failure to Provide Recommended Behavioral Health Services After Suicidal Ideation
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of depression and a history of expressing suicidal ideation received the recommended behavioral health services. The resident, who had multiple diagnoses including muscle wasting, depression, diabetic foot ulcer, and Parkinson's disease, was admitted on 12/14/24. Documentation in the clinical record showed that the resident had wrapped a call bell cord around their neck and expressed a desire not to live. Following this incident, there were notations indicating that the resident was placed on every 15-minute checks for safety. A psychiatric evaluation conducted on 3/04/25 recommended that the resident continue with behavioral health services. However, further review of the clinical record did not show evidence that these recommended services were provided after the evaluation. During an interview, the Nursing Home Administrator confirmed that there was no documentation indicating the continuation of behavioral health services for the resident, despite the recommendation and the resident's ongoing risk factors.