Failure to Provide Behavioral Health Services for Resident with Suicidal Ideation
Penalty
Summary
A resident with a history of suicide attempt, major depressive disorder, generalized anxiety, bipolar disorder, agoraphobia with panic disorder, and insomnia was admitted to the facility. Hospital records indicated the resident was at risk for suicide and required one-to-one supervision during a prior hospital stay. Upon admission, the care plan identified the resident as being at risk for mood problems due to previous suicide attempts, with interventions including behavioral health consultations as needed. Despite multiple documented requests from the resident for psychological services and staff notes indicating ongoing anxiety, depression, and suicidal ideation, there was no evidence that the resident was ever assessed or treated by a behavioral health provider during their stay. Staff interviews confirmed that the resident was not seen by behavioral health services since admission. On several occasions, the resident expressed feelings of wanting to hurt herself and requested to see a therapist, but there was no documentation of behavioral health follow-up or assessment. The situation escalated when the resident was found with multiple lacerations to her neck after using scissors obtained from a roommate in a suicide attempt. This incident followed repeated expressions of distress and requests for behavioral health support, which were not met with timely or documented intervention by behavioral health professionals.