F0656

D

Failure to Timely Care Plan for Resident Suicidal Ideation

Batesville, Indiana Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely develop and update a care plan addressing suicidal ideation for a resident with documented suicide risk. The resident, who was cognitively intact, had diagnoses including traumatic brain dysfunction, anoxic brain damage, anxiety, and depression, and was documented as having little interest or pleasure in activities nearly every day, feeling down or hopeless at least half the days, feeling tired nearly every day, and feeling bad about themself. On one afternoon, a progress note documented a change in condition when the resident requested Adderall and was informed it was not due; the resident then began crying, pointed to their neck, and mouthed words that the LPN eventually interpreted as the resident stating they wanted to kill themself. The progress note indicated the resident was considered a danger to self or others for suicide potential, and the physician was notified.

Despite this documented suicidal statement and identification of suicide potential, the resident’s care plan did not include any care plan addressing suicidal ideation until several weeks later. The LPN confirmed in interview that the resident had asked for more Adderall, became visibly upset and tearful, and affirmed that they wanted to kill themself when asked directly. The Social Service Director stated that residents are care planned for suicidal ideation when a nurse asks if they want to kill themself and the resident says yes, and acknowledged that this would be considered suicidal ideation. The facility’s policy on Baseline and Comprehensive Care Plans requires that every resident have a care plan that expands on mental and psychosocial needs, but the care plan for this resident lacked an intervention for suicidal ideation during the period following the documented suicidal statement.