Failure to Revise Care Plan After Suicidal Ideation Incidents
Penalty
Summary
The facility failed to review and revise the care plan with appropriate interventions for a resident with a history of suicidal ideation and multiple psychiatric diagnoses, including paranoid schizophrenia, bipolar disorder, hallucinations, psychosis, anxiety, and depression. Despite physician orders to monitor behavioral occurrences every shift and an existing care plan that addressed general behavioral issues, the care plan did not specifically address the resident's suicidal ideations with intent or include personalized interventions following incidents where the resident expressed intent to self-harm. Notably, after the resident verbalized wanting to harm themselves with a weighted silverware knife and was subsequently transferred to the ER for psychiatric evaluation, there was no documented revision to the care plan upon their return from the hospital. Further, after additional episodes where the resident reported hearing voices instructing them to harm others and was again transferred for psychiatric evaluation, the clinical record still did not reflect any updates or new interventions in the care plan. Interviews with the Director of Nursing confirmed that the care plan was not revised after these incidents, and there was uncertainty about whether updates were necessary. Facility policy required episodic review and revision of the care plan, especially after hospital readmissions, but this was not followed in these instances.