Failure to Provide Appropriate Supervision for Suicidal Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed mental and psychosocial adjustment difficulties, specifically suicidal ideation. The resident, who had diagnoses of dementia, anxiety, and cognitive decline, was grieving the loss of their spouse and had a history of severe cognitive impairment as indicated by a BIMS score of 4. On the day of the incident, staff removed potentially harmful objects from the resident's room after the resident expressed suicidal thoughts and behaviors, including statements about self-harm and intent to die. The resident's family confirmed concerns about suicidal ideation. The resident became agitated, and their roommate was relocated for safety. The resident was placed on every 15-minute checks for suicide prevention until being transferred to the hospital. Despite these interventions, the facility did not implement a one-to-one observation for the resident when they were actively suicidal, as confirmed by both the Nursing Home Administrator and the Nurse Practitioner. Facility policy and staff interviews indicated that one-to-one observation is expected in such situations to ensure the resident is not left alone. The failure to provide this level of supervision constituted a deficiency in ensuring the resident received appropriate treatment and services for their mental and psychosocial needs.