Failure to Provide Appropriate Mental Health Services for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with mental or psychosocial adjustment difficulties. The resident, who had diagnoses of depression and adjustment disorder with depressed mood, was identified as a suicide risk and had expressed suicidal ideation. On one occasion, a nurse aide found the resident attempting self-harm by wrapping a telephone cord around their neck and expressing a desire to die. Despite facility policy requiring immediate reporting, assessment, and supervision of residents expressing suicidal ideation, there was no documentation that the resident displayed suicidal ideations or behavioral issues on the day of the incident. Additionally, a registered nurse did not assess the resident immediately after the suicide attempt, contrary to facility policy. Further review revealed that although the resident was instructed to follow up with psychiatry after a hospital visit and a physician ordered a psychiatric consult, there was no evidence in the clinical record that the resident was seen by psychiatry as ordered. Interviews with facility staff, including the DON and Nursing Home Administrator, confirmed that the required assessments, monitoring, and psychiatric consultation were not completed as per policy for a resident displaying mental health difficulties and suicidal ideation.