Failure to Supervise and Protect Resident with Suicidal Ideation
Penalty
Summary
The facility failed to keep a resident with known suicidal ideation and a history of suicide attempt free from hazards and did not provide the necessary monitoring and supervision as required by facility policy and physician orders. The resident, who had diagnoses of depression and adjustment disorder, was found on multiple occasions with a cord wrapped around their neck and expressing suicidal ideation. Despite these incidents, there was no evidence that the required 1:1 supervision or every 15-minute checks were implemented or documented as ordered by the physician and outlined in facility policy. Facility policy required that any suicide threats be taken seriously, with immediate reporting to the nurse supervisor or charge nurse, and that a staff member remain with the resident until further assessment. The policy also required removal or securing of items that could be used for self-harm, such as cords and plastic liners. However, observations revealed that cords in the resident's room, including bed control cords, call bell cords, and telephone cords, were not secured and remained accessible. Additionally, the resident's roommate also had unsecured cords in the shared room. Interviews with staff confirmed that after the resident was found with a cord around their neck and expressing suicidal ideation, appropriate assessments and monitoring were not performed. Staff were unclear about documentation procedures and did not consistently implement or record the required supervision. The DON and NHA acknowledged the lack of evidence for required monitoring and supervision, and staff interviews further confirmed that facility policies were not followed in response to the resident's suicidal behavior.
Removal Plan
- Resident R96 will be provided with a safe environment by securing bed control cord, call bell cord, and telephone cord so cords are not accessible to resident to harm self. Roommate's cords have also been secured. The room has also been checked for any other hazardous items to ensure a safe environment.
- Physician orders for monitoring resident BP will be completed by nursing staff every 15 minutes to ensure resident safety.
- Residents will be evaluated by psychiatric services for safety.
- Care plan will be reviewed and updated.
- The Director of Nursing or designee will complete a house audit of all residents for suicidal ideations. A resident questionnaire on suicidal ideation will be used for all residents with a BIMS of 9 or above. Residents with a BIMS of 8 or below, a resident skin check and review of risk management to determine resident's safety.
- Care plans will be updated to reflect the residents' current condition by Licensed Practical Nurse Assessment Coordinator (LNAC) or designee.
- A house audit of environment will be completed by Environmental Services Supervisor or designee to validate no hazards are identified for residents with suicidal ideations.
- The NHA, DON and Regional Clinical Consultant will review and update the facility policy and procedures for Suicidal Threats and Supervision of Residents with suicidal ideations.
- All staff will be re-educated on the facility policy and procedures for Suicidal Threats, Care Plans and Supervision of residents identified with suicidal ideations.
- All incidents and accidents will be reviewed and results reported to the Quality Assurance and Process Improvement Committee for review and frequency of audits.