Failure to Implement Care Plan for Resident Expressing Suicidal Ideation
Penalty
Summary
A deficiency occurred when staff failed to implement a resident's care plan interventions after the resident expressed suicidal ideation. The resident, who had a history of chronic suicidal ideation, mild cognitive impairment, legal blindness, abnormal gait, osteoarthritis, and anxiety disorder, repeatedly stated she wanted to kill herself. Despite these statements, Certified Nursing Assistants (CNAs) did not notify the nurse on duty or the Nurse Care Coordinator as required by the care plan. The care plan specifically directed staff not to leave the resident alone, to immediately notify nursing staff, and to provide one-to-one supervision until a nurse could assess the resident's safety and implement further interventions. On the day of the incident, the resident was found alone in her room, repeatedly calling for help and expressing a desire to die. Staff present on the unit acknowledged that the resident often made such statements and described their response as attempting to calm her and documenting the behavior, but did not escalate the situation to nursing staff for assessment. The CNAs reported that when the resident was disruptive, she was placed in her room alone to avoid agitating other residents, contrary to the care plan's instructions. There was no documentation in the progress notes of the resident's suicidal statements on the day in question, and neither the nurse on duty nor the Nurse Care Coordinator were informed of the incident. Both confirmed in interviews that they had not been notified and that the care plan should have been followed, including immediate assessment and supervision. The Director of Nursing also confirmed that the care plan's directives were not implemented as required.