Failure to Provide Timely Social Services for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide sufficient and timely medically-related social services to a resident with a known history of suicidal ideation, schizophrenia, and anxiety disorder. The resident was admitted with these diagnoses and had previously received therapeutic services, which were discontinued in October due to reported cognitive decline and lack of communication with the therapist. After the discontinuation of therapy, there was no evidence of further clinical therapeutic services or psychotropic medication management for the resident from October through December. In early December, staff documented that the resident expressed feelings of purposelessness and made statements indicating suicidal ideation. The resident also attempted self-harm using plastic utensils on two occasions. Despite these incidents and the resident's ongoing expressions of distress, there was no documentation that the facility contacted the clinical therapist or nurse practitioner for further evaluation or intervention. Interviews with staff confirmed awareness of the resident's recurring distressing dreams and mental health concerns, yet no additional social services or therapy were provided during this period.
Plan Of Correction
Resident R7 was sent to hospital on December 6, 2025, and Social Services needs would be addressed when she returned. No other residents currently present with suicide ideations that need further social service interventions. The Director of Nursing or Designee will educate Social Services on protocol when a resident with suicide ideation discusses dreams to provide the necessary therapy or interventions. Social Services or designee will audit resident prevention with suicide ideations weekly times 3 and monthly times 2. Results will be turned into monthly Quality Assurance meetings.