Failure to Provide Adequate Supervision for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide adequate supervision for a resident with significant mental health concerns, resulting in multiple suicide attempts. The resident, who had diagnoses of suicidal ideation, schizophrenia, and anxiety disorder, expressed feelings of hopelessness and made statements about not wanting to be alive. On two consecutive days, the resident attempted self-harm using plastic utensils—a fork and a spoon—despite staff being aware of her mental health status and recent expressions of suicidal ideation. Facility policies required immediate safety interventions for residents with suicide ideation or attempts, including one-on-one observation, removal of potential means for self-harm, and urgent mental health evaluation. However, the clinical record and staff interviews confirmed that these measures were not adequately implemented for this resident, as she was able to access items to attempt self-harm and was not under continuous supervision as required by policy.
Plan Of Correction
Resident R7 was sent to hospital on December 6, 2025, and escorted by a staff member during transport. No other residents presented with suicide ideations currently that needed one-to-one care. The Director of Nursing or Designee will educate nursing staff on protocol when a resident with suicide ideation starts to act on them. The Director of Nursing or Designee will audit resident prevention with suicide ideations weekly times 3 and monthly times 2. Results will be turned into the monthly Quality Assurance meeting.