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F0740
D

Failure to Provide Necessary Behavioral Health Services Following Resident's Expression of Not Wanting to Live

Jefferson, Wisconsin Survey Completed on 06-23-2025

Penalty

10 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to ensure that a resident received necessary behavioral health care and services to maintain the highest practicable mental and psychosocial well-being, as required by the comprehensive assessment and care plan. The resident, who had a history of depression, adjustment disorder, and other significant medical conditions, expressed to a CNA that they did not want to live. Despite this statement, there was no documentation that a suicidal evaluation was completed, the physician or psychologist was notified, or a care plan was developed to address the resident's depression or mood concerns. The facility's policy required staff to assess and respond to expressions of suicidal ideation or passive death wishes, including offering psychosocial support and developing a care plan for passive statements. However, after the resident's statement, the RN instructed the CNA to notify social services but did not follow up with the resident or ensure an assessment was completed. There was also no evidence that the psychologist was informed of the resident's statement, and no care plan was initiated to address the resident's depression, even after subsequent assessments indicated moderate depressive symptoms and a care area assessment recommended care planning for mood. Interviews with facility staff revealed a lack of clarity and follow-through regarding the appropriate response to the resident's statement. The RN could not recall which CNA reported the statement and did not know what interventions should have been implemented. The Director of Social Services stated the resident was not suicidal and did not complete an assessment at the time. The care plan did not address the resident's depression or its manifestations, and interventions for mood concerns were not documented, despite multiple triggers and recommendations for care planning.

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