Failure to Complete Suicide Ideation Assessment After Behavioral Change
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident for behavioral health needs, specifically suicidal ideation, following a change in behavior. Intake documentation showed that the resident was transported to the hospital for a behavioral emergency. A social services progress note, entered late and dated two days before the hospital transfer, documented that social services visited the resident due to staff concerns about the resident’s welfare and behavior. During that visit, the resident was described as calm, pleasant, and redirectable, and there was no documentation that a suicide ideation assessment interview was completed. Subsequent review of clinical documentation revealed that a late-entry nursing note, written several days after the events, indicated that a nursing assistant had reported the resident stated they wanted to die. This late-entry note, referring to an earlier date, was not available in the record at the time the social worker evaluated the resident, and the social worker reported being unaware that the resident had voiced a desire to die. Later documentation showed that the resident was found lying on the floor with a plastic bag over their head and was assessed and transported to the hospital, with police, physician, and family notified. Review of the facility’s suicide precaution management policy showed that a brief suicide ideation assessment was required for any current resident who voiced or indicated suicidal ideation in any manner, but such an assessment was not completed for this resident.
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