Failure to Remove Environmental Hazards and Implement Safety Interventions for Resident with Suicidal Ideation
Penalty
Summary
A deficiency occurred when the facility failed to remove environmental hazards and implement appropriate safety interventions for a resident with a history of mental disorders, including suicidal ideation, paranoid schizophrenia, bipolar disorder, hallucinations, psychosis, anxiety, and depression. The resident expressed suicidal ideation and intent on multiple occasions, resulting in four transfers to the emergency department over a 38-day period. Despite these incidents, the clinical record showed no timely revisions to the resident's care plan or mitigation of environmental risk factors, such as access to knives and other potentially harmful items. The resident was observed on several occasions with access to silverware, including butter knives, and was seen rubbing a knife against their wrist while expressing intent to self-harm. Staff interviews and documentation revealed that the resident was able to obtain knives from meal trays, and there was a lack of immediate action to restrict access to these items following repeated episodes of suicidal ideation and self-harm attempts. The facility's documentation did not reflect prompt updates to the care plan or consistent removal of environmental hazards, such as corded call lights and phone chargers, even after the resident's behaviors escalated. Multiple staff members, including nursing and medical personnel, indicated that access to knives and metal silverware did not pose a safety risk, despite the resident's documented history and visible evidence of self-harm. Observations confirmed that hazardous items remained accessible in the resident's environment after incidents of suicidal ideation and self-harm. The facility's failure to promptly identify and address these environmental risks contributed to repeated episodes of suicidal behavior and inadequate protection for the resident.