Failure to Monitor and Intervene for Residents at Risk of Self-Harm
Penalty
Summary
The facility failed to provide necessary monitoring and supervision for a resident with a known history of suicidal ideation and prior incidents involving the acquisition of knives. Despite documented evidence of the resident's mental health diagnoses, including major depressive disorder and previous threats and attempts of self-harm, the facility did not implement or document consistent safety interventions such as regular room searches or removal of sharp objects. The resident was able to keep multiple knives in his room, which were ultimately used in a fatal self-inflicted injury. Staff interviews revealed that although the resident had previously been placed on one-to-one supervision and had knives confiscated, there was no ongoing system to prevent the reintroduction of dangerous items, nor was there documentation of education or consistent safety checks. The facility also lacked a timely and accurate system for screening residents for suicide risk. The suicide risk assessment tool in use was not applied as intended; staff responsible for completing the assessments altered the scores from moderate to low risk without clinical justification, and did not repeat screenings quarterly or after significant changes in condition or new threats of self-harm. This practice was not limited to one resident; multiple residents with moderate risk scores had their assessments inappropriately lowered, and corresponding care plans were not developed or updated to address the actual risk level. Documentation showed that care plan interventions for suicide risk were either not implemented or were only to be used "as warranted," with no clear criteria or consistent application. The failure to accurately identify, monitor, and intervene for residents at risk of self-harm resulted in a resident sustaining fatal self-inflicted stab wounds. The lack of a systematic approach to suicide risk screening, care planning, and environmental safety checks placed all residents with a history of suicidal ideation at risk. The deficiency was identified as Immediate Jeopardy due to the facility's lack of effective interventions and processes to protect residents from harm.
Removal Plan
- R5 - R17's suicide risk screening has been reviewed, reassessed and revised.
- R5 - R17's Care plans were audited to ensure appropriate interventions are in place and were updated as necessary.
- All residents' self-harm care plans were reviewed and updated as necessary by Social Service Director (SSD), MDS coordinator and or designee.
- The facility identified no other residents who were at risk of self-harm and had a significant history of obtaining knives or other potential weapons identified via audit /record review.
- Of those residents who did have a suicide ideation/verbalization there were no significant findings identified via room search, placing them at risk for self-harm.
- All residents' suicide risk screenings were audited and updated as necessary.
- All residents self-harm care plans were reviewed and updated where necessary.
- SSD/designee is responsible for completing suicide risk screening assessments and have been in-serviced by V20 (Consultant Social Worker), V21 (RNC-Regional Nurse Consultant) completing self-harm/suicide risk screening assessments accurately, including properly recording the assessment score, completing timely and accurately with appropriate, individualized interventions in place.
- Suicide risk assessments need to be completed upon admission, quarterly, upon significant changes, and as needed.
- The facility created a process to address the results of the self-harm/suicide risk screening assessment to ensure recommendations from the screening, and measurable care plan interventions are put in place to instruct staff on how to keep residents safe.
- The facility created a policy and guidelines to the self-harm/suicide risk assessment and implemented.
- Nursing staff were in-serviced by DON/ADON (Director of Nursing/Assistant Director of Nursing) to ensure that residents with suicidal ideation will be monitored every shift under behavior monitoring and will be documented in the EMR (Electronic Medical Record).
- Residents with a history of obtaining sharp objects will have room searches conducted during angel rounds as permitted by residents or POA (Power of Attorney).
- An audit tool will be completed by Administrator, DON and or ADON on every resident upon admission, re-admission, quarterly and with significant changes to ensure that suicide risk screening assessments are completed accurately with appropriate individualized care plans as follows: Three times a week for the first two weeks, two times a week for two weeks, one time week for two weeks, and one time a month for two months.
- QAPI (Quality Assurance Performance Improvement) Committee will review for compliance, and determine that compliance has been met.
- An emergency QAPI meeting was held and attended by the Medical Director and interdisciplinary team.