Failure to Timely Report Resident Suicidal Ideation and Medication Hoarding
Penalty
Summary
The facility failed to ensure that an incident involving a resident's suicidal ideation and medication hoarding was reported to the State Survey Agency as required. A resident with diagnoses including schizophrenia, depression, anxiety disorder, and dementia informed the social worker that he intended to commit suicide and had hoarded 21 pills in his locked bedside table for this purpose. The social worker immediately notified the administrator (ADM) and director of nursing (DON), and the resident was subsequently sent to a psychiatric hospital for evaluation and stabilization. Despite the seriousness of the incident, a review of facility records and interviews revealed that the event was not reported to the state agency as required by regulation. The DON confirmed that an internal incident report was only being completed several days after the event and acknowledged that the incident was not reported to the state. The ADM stated that he did not believe the incident needed to be reported since the resident had not consumed the medication and there was no harm at the time, despite recognizing the potential for harm if the plan had been carried out. The facility's policy required all accidents or incidents, including those involving allegations of abuse or neglect, to be reviewed, investigated, and reported to the administrator immediately. However, there was no specific policy outlining the reporting requirements for different types of incidents. The lack of timely reporting of this incident involving suicidal ideation and medication hoarding constituted a deficiency in the facility's compliance with state reporting requirements.