Failure to Immediately Notify Provider After Resident Self-Harm Attempt
Penalty
Summary
The facility failed to immediately notify the resident's physician when there was a significant change in a resident's mental and psychosocial status, specifically following a self-harm attempt. The resident, a 52-year-old woman with a history of bipolar disorder, generalized anxiety disorder, mild cognitive impairment, paranoid schizophrenia, schizoaffective disorder, paranoid personality disorder, and legal blindness, was found by staff with the belt of her robe tied around her neck and attached to her bed rail. The incident was discovered by a CNA, who alerted the RN on duty. The RN assessed the resident, found no injuries or changes in vital signs, and contacted the on-call ADON, who instructed the RN to initiate 15-minute checks. However, the resident's physician or nurse practitioner was not notified of the incident at that time. Documentation and interviews revealed that the resident had previously shown no signs of suicidal ideation or self-harm in recent assessments and psychological notes. After the incident, the resident was placed on increased supervision, including 15-minute checks and later 1:1 monitoring. Multiple staff interviews confirmed that the RN did not consider the event an emergency due to the resident's stable condition and lack of physical injury, and therefore did not notify the provider. The ADON, upon being informed, was not told the full extent of the incident and also did not contact the provider. The provider was only notified the following morning, after further review by the DON. Staff interviews indicated that they had received in-service training on recognizing and responding to signs of depression, suicidal ideation, and self-harm, and that the expectation was to notify the provider immediately in the event of a self-harm attempt. The facility's policy also required immediate notification of the physician in urgent situations. Despite these protocols, the failure to notify the provider immediately after the self-harm attempt constituted a deficiency in ensuring timely medical intervention and continuity of care.