Failure to Provide Timely Behavioral Health Interventions After Residents Expressed Suicidal Ideation
Penalty
Summary
The facility failed to ensure that two residents received necessary behavioral health care and services after each expressed a desire to die. One resident, a female with terminal cancer on hospice care, made statements such as "let me die, leave me alone" and explicitly stated she wanted to die. Despite these statements, there was no documentation that the resident's physician was notified, nor was there evidence of a psychiatric evaluation, social services assessment, or any behavioral health intervention following her statements. Interviews with facility staff, including the DON, social worker, and LVN, confirmed that no immediate assessment or intervention was initiated, and the required notifications and documentation were not completed as per facility policy. Another resident, a male with a recent colostomy and a history of anxiety disorder, also stated he wanted to die, reportedly due to pain and a recent room change. Although a psychiatric consult was eventually ordered, there was no immediate assessment or documentation of behavioral health interventions or increased supervision following his statement. Staff interviews revealed a lack of awareness of the resident's statements and inconsistent understanding of the procedures to follow when a resident expresses suicidal ideation. The social worker did not assess the resident until hours after being notified and did not specifically address the resident's statement about wanting to die during her assessment. Both cases demonstrated a failure to follow the facility's behavioral health policy, which requires immediate assessment, notification of appropriate staff, and documentation when a resident expresses suicidal ideation or a significant change in mood. The lack of timely response and intervention placed the residents at risk of mental and psychosocial harm, as the facility did not provide the necessary behavioral health care and services in accordance with the comprehensive assessment and plan of care.