Failure to Provide Appropriate Behavioral Health Services for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with Huntington's Disease and exhibiting significant mental and psychosocial adjustment difficulties, including repeated suicidal ideation and attempts. Over a period of time, the resident was observed by staff attempting to open windows in their own and other residents' rooms, verbalizing intentions to jump out, and displaying increased agitation and behavioral disturbances. Despite multiple incidents where the resident was transferred to the hospital for behavioral evaluation after expressing or acting on suicidal ideation, upon return to the facility, the resident was placed back in the same room without updates to their care plan or implementation of new interventions to address the ongoing risk behaviors. Documentation revealed that the resident's care plan was not revised to reflect the repeated suicidal ideations and behaviors, nor were consistent or effective monitoring interventions implemented. The resident was at times placed on 1:1 monitoring, but after returning from the hospital following a suicide attempt, was only placed on 30-minute visual checks. Staff interviews indicated a lack of communication and awareness among facility leadership and clinical staff regarding the resident's repeated hospitalizations and behavioral health needs. Additionally, recommendations from hospital providers, such as medication adjustments, were not consistently reviewed or acted upon by the facility's medical staff. On the night of the fatal incident, the resident returned from the hospital and was placed on 30-minute checks. Within hours, the resident was found outside the window, having removed the window panel, and subsequently fell from the fourth floor, resulting in death. The facility's investigation concluded the event was unforeseeable and attributed it to the resident's neuropsychiatric condition, but there was no evidence that the care plan had been updated or that effective interventions were implemented following prior incidents. The deficiency was cited as immediate jeopardy due to the facility's failure to ensure the resident received necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being.