Failure to Provide Timely Behavioral Health Services After Self-Harm and Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to timely and appropriately provide behavioral health services to a resident with depression, anxiety, and altered mental status. The resident was cognitively intact on admission. On one date, nursing notes documented that therapy staff reported several marks on the resident’s neck. The resident denied self-harm and suicidal ideation, but the facility initiated suicide precautions, including 15-minute checks and removal of cords and other potentially harmful items, and contacted crisis intervention. Crisis intervention assessed the resident and determined the resident was not in crisis, and a psychiatry consult documented a linear scratch on the neck, no concerns, and no suicidal or homicidal ideation or hallucinations. The psychiatrist recommended starting Hydroxyzine and follow-up in 4–6 weeks or PRN. Later that same day, nursing notes documented that the resident’s son reported the resident had admitted to using a picture frame in the room to hurt themselves and feeling depressed due to health issues, loss of independence, and increased confusion. The next day, social services documented that the granddaughter reported the resident told the son they had tried to kill themselves by grabbing glass from a picture frame and cutting their neck. The DON confirmed that the resident had informed the son they tried to hurt themselves with glass from a picture frame and that slashes were observed in the resident’s reading book sleeves. The picture frame was never found. Despite these reports and the psychiatrist’s recommendation for PRN follow-up, there was no documentation that a follow-up behavioral health consult was requested after the resident’s admission of self-harm with glass. Subsequently, the resident requested hospitalization for abdominal pain and was sent to the ER, where hospital records documented fecal impaction and suicidal ideations, along with a behavioral health consult. ER documentation indicated the resident admitted attempting to kill themselves a few days earlier by scratching their neck with glass and attempting to wrap a cord around their neck. The ER behavioral health consult recorded similar statements and recommended follow-up with the primary care physician and restarting counseling. After return to the facility, nursing notes documented delusional statements, increased anxiety, paranoia, wandering, refusal of medications, and statements about impending death and religiously themed thoughts involving judgment and the devil. There was no documented evidence that the primary physician was notified of the resident’s increased anxiety, paranoia, and delusions after the hospital transfer, and no documented evidence that behavioral health followed the resident until several weeks later, despite the ER behavioral health recommendations and the resident’s repeated reports of suicidal ideation and self-harm attempts.
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