Failure to Provide Timely Behavioral Health Interventions for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with multiple mental health conditions, including dementia, major depressive disorder, post-traumatic stress disorder (PTSD), and anxiety disorder. The resident had a documented history of suicidal ideation and self-harm attempts, including a prior incident at another facility where she attempted to cut her neck. Despite these known risks, the facility did not address suicidal ideations in the resident's care plan, nor were interventions implemented following multiple episodes where the resident expressed suicidal thoughts or attempted self-harm. On several occasions, staff documented the resident expressing a desire to die, crying, and making statements about wanting to harm herself. These episodes included the resident attempting to exit the building, grabbing potentially dangerous objects such as scissors and a lamp, and threatening self-harm. In each instance, while staff responded to the immediate situation by removing objects and contacting the physician or family, there was no evidence that a psychiatric, psychological, or behavioral assessment was conducted immediately following these incidents. The care plan was not updated to reflect the resident's suicidal ideations, and no new interventions were put in place to address her ongoing mental health needs. Additionally, the facility failed to consider the impact of roommate assignments on the resident's mental health. The resident expressed increased anxiety after being assigned a new roommate with whom she did not get along, yet no interventions or changes were made in response to her concerns. Interviews with staff revealed confusion and lack of clarity regarding responsibilities for updating care plans and implementing interventions for residents with behavioral health needs. The facility's own policy required immediate reporting and intervention for suicidal ideation, but these procedures were not followed in practice.