Failure to Provide Behavioral Health Services Following Suicidal Ideation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents who expressed suicidal ideation, resulting in one resident successfully committing suicide. One resident, with diagnoses including Alzheimer's disease, major depressive disorder, anxiety disorder, and insomnia, repeatedly expressed feelings of depression, hopelessness, and suicidal thoughts to staff over several months. Documentation shows that this resident made multiple statements about wanting to die, feeling suicidal, and having no interest in life, yet there was no evidence that appropriate interventions or monitoring were implemented in response to these statements. In several instances, the resident's expressions of suicidal ideation were not communicated to the physician, and there was a lack of documented follow-up or increased supervision. The resident's medical record revealed a history of severe depression, agitation, and behavioral symptoms, with mood assessments indicating a high severity of depression. Despite these ongoing concerns, the only documented assessment by a Licensed Clinical Social Worker or mental health provider was conducted early in the resident's stay, and there was no evidence of ongoing behavioral health interventions or monitoring tailored to the resident's escalating risk. The resident continued to display signs of isolation, agitation, and suicidal ideation, including direct statements about wanting to die and refusing to participate in activities or meals. Ultimately, the resident was found deceased in his room after a successful suicide attempt, with no documentation of suicide prevention measures having been implemented prior to the event. A second resident also made statements about wanting to hang himself, but there was no documentation that behavioral health services, interventions, or monitoring were provided in response. The facility's failure to act on clear indications of suicidal ideation and to implement necessary behavioral health care and services for both residents constituted a deficiency at the Immediate Jeopardy level, as it did not ensure the residents' highest practicable physical, mental, and psychosocial well-being in accordance with their comprehensive assessments and care plans.