Failure to Provide Behavioral Health Services and Ensure Resident Safety
Penalty
Summary
The facility failed to provide necessary behavioral health services and to maintain or improve the psychosocial well-being of a resident with significant mental health diagnoses, including bipolar disorder, depression, generalized anxiety disorder, personality disorder, suicidal ideations, and a history of intentional self-harm. The resident experienced frequent and escalating episodes of suicidal ideation, self-injurious behaviors such as punching herself and banging her head, and made multiple statements about plans to strangle herself. Despite these ongoing behaviors and repeated hospitalizations, the facility did not consistently implement increased monitoring, remove hazardous objects from the resident's environment, or ensure referral for recommended counseling services as documented in medical records and care plans. Staff interviews and record reviews revealed a lack of awareness and follow-through regarding physician orders for 15-minute checks, inconsistent or absent documentation of monitoring, and confusion among staff and leadership about when and how increased supervision was to be provided. Hazardous items such as cords, blankets, plastic bags, and a folding chair were observed in the resident's room, and staff were unaware of the presence of some of these items, including a call light cord in the bathroom. The resident was often left unsupervised despite expressing active suicidal ideation and having a clear plan, and staff had not received training on managing suicidal behaviors or behavioral health care. The facility also failed to make or follow up on referrals for counseling services as recommended by outside providers. Interviews with facility leadership, nursing staff, and consulting psychiatric professionals confirmed that the facility was not equipped to meet the resident's behavioral health needs and that there was a lack of appropriate interventions and staff training. The resident continued to experience frequent crises, including multiple transfers to emergency rooms and psychiatric facilities, and voiced ongoing feelings of isolation and suicidal thoughts. The failure to provide necessary behavioral health care and to maintain a safe environment resulted in an Immediate Jeopardy situation, as the resident remained at risk for self-harm due to the facility's inaction and lack of appropriate behavioral health interventions.