Failure to Complete Suicide Risk Evaluations for Resident Expressing Suicidal Ideation
Penalty
Summary
The facility failed to ensure that suicide risk evaluations were completed for a resident who exhibited and verbalized significant changes in mental health status, including suicidal ideation. Multiple staff members, including CNAs and environmental services, observed and reported changes in the resident's behavior, such as increased irritability, frequent shirt changes, giving away personal belongings, and direct statements expressing a desire to die or commit suicide. These observations and comments were communicated to nursing staff, but no suicide risk evaluation was completed at the time of the initial comments. The resident had a complex medical history, including paranoid schizophrenia, COPD, diabetes type two, CHF, and chronic kidney disease. The resident's psychiatric medication, clozapine, was tapered off following a cardiologist's recommendation, which led to increased behavioral symptoms and further mental health deterioration. Despite weekly behavioral health visits and multiple documented statements of suicidal ideation in the electronic medical record, suicide risk assessments were not performed after these statements, nor was the care plan updated to reflect the resident's expressed suicidal thoughts until after a self-harm incident occurred. Nursing staff, including an LPN and an RN, acknowledged that they did not complete suicide risk evaluations following the resident's comments, as they did not believe the resident was serious. Both staff members had received education on suicide precautions but were either unaware of the specific assessment required or did not apply it. The facility's policy required a suicide risk evaluation and care plan update when a resident verbalized suicidal ideation, but these procedures were not followed until after the resident harmed himself.