Failure to Supervise Resident with Suicidal Ideation and Maintain Safe Environment
Penalty
Summary
The facility failed to provide necessary supervision and services for a resident with a documented history of suicidal ideation and suicide attempts. Despite the resident expressing suicidal thoughts and requesting psychological services on multiple occasions, there was no evidence that staff implemented one-to-one observation, conducted timely assessments, or ensured the resident was seen by behavioral health services as required by facility policy. The resident was able to access a sharp object from her roommate and attempted suicide while in the facility, indicating a lack of adequate supervision and failure to follow established protocols for residents at risk of self-harm. Additionally, the environment was not maintained free from accident hazards. A resident was able to keep sharp objects, including a knife and scissors, in her room, and these items were accessible to others, including a roommate with a history of suicidal ideation. Observations revealed that the key to a locked drawer was left in the lock, making it easy for anyone to access potentially dangerous items. Furthermore, unattended and unlocked treatment and medication carts containing sharp objects and button batteries were observed in resident-accessible areas, with scissors left on top of medication carts in the presence of ambulatory residents and visitors. Staff interviews confirmed that the resident with suicidal ideation was not placed on one-to-one observation and had not been seen by behavioral health services since admission. The facility administrator acknowledged the lack of evidence for implementing safety interventions or staff education following the suicide attempt. The combination of inadequate supervision, failure to follow policy, and unsafe environmental conditions led to an Immediate Jeopardy situation.