F0689

J

Failure to Secure Windows and Address Suicide Risk Leading to Resident Jumping from Second-Floor Window

Scranton, Pennsylvania Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and environmental safety for a resident with significant mental health needs. The resident was admitted with anxiety, major depressive disorder, a documented history of suicide attempts, and prior inpatient psychiatric hospitalizations. The admission MDS showed the resident was cognitively intact, and the PASRR identified a Level II status for serious mental illness. Clinical notes over the ensuing weeks documented persistent and worsening depression, anxiety, pacing, restlessness, and episodes of self-harm behavior such as repeatedly striking his head against the wall. Psychology and psychiatric notes described high anxiety, guarded behavior, feelings of being trapped, visual hallucinations, and major depressive disorder with psychotic disturbance. The resident and spouse, who shared the same room, were known to have had numerous attempted joint suicides with psychiatric hospitalizations.

Despite this history and ongoing symptoms, the resident’s care plan for depression and anxiety, initiated shortly after admission, did not include the resident’s documented history of suicide attempts until after the incident. Staff notes repeatedly described escalating anxiety, restlessness, frequent pacing in the room and hallways, and staff difficulty redirecting the resident. Staff and psychiatric providers reported frequent falls likely related to increased restlessness and worsening mood disturbances. The resident expressed a desire to go home, reported feeling dizzy and trapped, and was described as extremely anxious, with his wife identified as a trigger for his distress. Although separation from his wife and psychiatric follow-up were discussed, there is no indication in the report that increased supervision or specific suicide-risk precautions were implemented before the event.

On the day of the incident, the RN supervisor assessed the resident for vomiting and difficulty urinating, noted no abdominal distension, and then left the room after the resident became verbally abusive, laid himself on the floor, and then returned to bed independently. Approximately 15 minutes later, the resident’s wife alerted staff that he had jumped out of the second-floor window. The resident had been alone in the room with his wife at the time. Facility investigation and interviews revealed that the window from which the resident exited could be opened fully without restriction, and the screen had been knocked out. The Maintenance Director stated that windows were not routinely inspected and had last been checked a year prior. Observations showed that while some windows in the facility had rubber stoppers limiting opening to a few inches, other windows, including the one in this resident’s room, did not have such devices. The facility’s investigative documentation initially claimed the resident had removed safety screws, but interviews and observations established that no such screws were in place on that window prior to the incident, and that screws were first installed after the event. Additional observations found other windows in resident-accessible areas that could open widely without restriction, demonstrating a broader failure to ensure window security and environmental safety.

Removal Plan

• Resident 1 was transported from the facility to the hospital emergency room and admitted; a safety device was placed in all windows in the facility that would not allow them to open past 4 inches.
• An audit was completed of all windows in residents' rooms and common areas to ensure that window safety devices are in place.
• Residents with a history of suicide attempts will be reviewed to ensure they have psychiatric services in place, psych medications are reviewed, care plans are updated if needed, and a suicide risk assessment is completed; if they trigger for suicide risk, appropriate actions will be taken per the facility Suicide Threats policy.
• Newly admitted residents will have their antidepressant medications reviewed and compared to their hospital discharge instructions to ensure that they are ordered correctly.
• Maintenance will ensure that all windows have been addressed so that they cannot open past 4 inches.
• Maintenance or a designee will perform random window safety audits.
• The DON/designee will audit all new admissions during morning meetings to check for a diagnosis or history of suicide attempts and ensure clinical recommendations are implemented if positive for suicidal ideations.
• The DON/designee will compare hospital discharge summaries for antidepressant medication orders to ensure they match the physician's orders.
• Results of audits will be presented to risk meetings and to the QAPI/QUAPI committee for further review and recommendations.
• All facility staff will be educated on suicide prevention, suicide threats, the six steps to identifying and addressing behavioral symptoms, and window safety.
• Maintenance or the designee will continue to monitor safety window checks.
• The DON/designee will continue to audit all new admissions during morning meetings for suicide-attempt history/diagnosis and implementation of clinical recommendations.
• The DON/designee will continue to compare hospital discharge summaries for antidepressant medication orders to ensure they match the physician's orders.