Failure to Develop Person-Centered Care Plan for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to develop and implement a person-centered care plan with appropriate interventions for a resident who had documented mental health diagnoses, including suicidal ideation, schizophrenia, and anxiety disorder. The resident's care plan listed 'suicidal ideations' as a focus but did not include a specific goal related to this issue, and the only intervention documented was the use of plastic silverware. No additional interventions or strategies to address the resident's suicidal ideation were included in the care plan or clinical record. Clinical progress notes revealed that the resident expressed feelings of purposelessness and made statements about not wanting to be alive. On two separate occasions, the resident attempted to harm herself using plastic utensils. Despite these incidents and the resident's mental health history, the care plan was not updated to include further interventions to address her suicidal ideation. The deficiency was identified through clinical record review and staff interviews, confirming the lack of a comprehensive, person-centered care plan for this resident.
Plan Of Correction
Resident R7 was at hospital and care plan was corrected upon her return. December 22, 2025. All residents with suicide ideations care plans were reviewed to make sure they were person-centered care plans. The Director of Nursing or designee will educate Nursing Administration staff on person-centered care plans for residents with suicide ideation. The Director of Nursing or designee will audit care plans with suicide ideations weekly times 3 and monthly times 2. Results will be turned into the monthly Quality Assurance meeting.