Failure to Provide Necessary Behavioral Health Services Resulting in Resident Suicide
Penalty
Summary
A facility failed to provide necessary behavioral health care and services to a resident with a diagnosed serious mental illness, resulting in the resident's suicide. The resident had a history of depression, prior suicidal ideations, and was admitted to the facility following a hospital stay where psychiatry had recommended 24-hour supervision, psychiatric medication management, and increased monitoring due to high suicide risk. Despite these recommendations, the facility did not implement increased supervision or update the resident's care plan to reflect active suicidal ideations and necessary interventions. The resident's care plan only indicated a history of suicidal ideations, not current risk, and staff were not instructed to monitor the resident more closely or search for means of self-harm in the resident's room. Documentation in the resident's medical record showed that after expressing suicidal ideations to a family member, there was no follow-up assessment or increased monitoring by staff. The primary care provider was not notified of the resident's suicidal statements, and there was no evidence of ongoing psychiatric follow-up or consistent behavioral health services after the initial mental health visit. The contracted mental health service did not have a routine schedule for seeing residents, and the resident was not seen again after the initial evaluation. Staff interviews revealed a lack of awareness regarding the seriousness of the resident's suicidal ideations and a failure to communicate critical information among the care team. The facility's own reference materials and professional standards outlined the need for close observation, psychiatric referral, and crisis intervention for residents with depression and suicidal ideations. However, these standards were not followed, as evidenced by the absence of increased supervision, lack of care plan updates, and failure to notify the primary care provider or implement safety interventions. The resident ultimately committed suicide in his room, and the incident was discovered by a CNA during routine rounds.