F0742

J

Failure to Provide Appropriate Mental Health Services and Monitoring for Resident With Self-Harm History

Bridgeville, Pennsylvania Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident with a history of self-harm and significant mental health diagnoses received appropriate treatment and services to address assessed psychosocial problems. The resident was re-admitted with diagnoses including toxic effects of glycols from suspected antifreeze ingestion, Parkinson’s disease, and depression. The resident’s care plan, updated on 10/30/25, identified a potential risk for ideations of self-harm related to PTSD, glycol toxicity, and hallucinations. Physician orders from 10/25/25 through 12/3/25 included psychiatry/psychology consultation and medications for insomnia, anxiety, depression, and overdose reversal, and progress notes documented a recent voluntary psychiatric hospitalization for Seroquel overdose and a history of possible self-harm attempts, which the resident denied.

Despite these identified risks and orders, the clinical record showed inconsistent behavior monitoring and a lack of documented behavioral health interventions to address the resident’s prior suicidal attempts or ideations. Behavior charting for October 2025 showed that 3 of 6 shifts lacked documented behavior monitoring, November 2025 had 24 of 90 shifts without documentation, and December 2025 had 26 of 61 shifts without documentation. The surveyor’s review of the medical records further noted a consistent lack of behavioral health interventions directed at the resident’s history of self-harm and suicidal ideation, even though the resident had a documented history of ethylene glycol toxicity, cocaine use, and Seroquel overdose, as well as recent psychiatric hospitalization.

The deficiency also includes the facility’s lack of an effective system to identify and manage residents with prior self-harm attempts. On 12/21/25, the resident was noted to have altered mental status and was transferred to the emergency room. On 12/22/25, the hospital notified the facility of a possible antifreeze ingestion and requested a search of the resident’s room, where staff found a gallon of Peak 50/50 Prediluted Antifreeze. During interviews, the NHA and DON stated they were unaware of the resident’s history of self-harm and acknowledged that the facility did not have a procedure to ensure residents with prior self-harm attempts were referred to mental health services. Surveyors determined that this failure resulted in actual harm to the resident, required hospitalization for antifreeze ingestion, and that there was no system in place to ensure other residents with similar needs were receiving appropriate mental health services, constituting an Immediate Jeopardy situation.

Removal Plan

• Complete an initial audit of current and new admissions to identify any resident with a diagnosis of suicide attempt or suicidal ideation and update care plans with interventions.
• Educate the admission director and clinical liaison to attempt to identify potential needs related to suicide attempts or suicide ideations prior to admission.
• DON or designee will educate staff regarding any new admission with a history of past self-harm attempts on plan of care needs.
• DON or designee will complete a weekly audit on new admissions to determine whether any resident with a history of suicide attempt or suicidal ideation is placed on psych services, has a care plan initiated, and has interventions added to the Kardex.
• Report audit results to the Quality Assurance Performance Improvement Committee.