F0580

D

Failure to Notify Physician/NP of Resident’s Self-Harm Threats and Mental Status Change

El Paso, Texas Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to consult with the resident’s physician or NP when there was a significant change in a resident’s mental status and when the resident voiced threats to harm herself. The resident was an older female with a complex medical history including fibromyalgia, rheumatoid arthritis, multiple sclerosis, COPD, osteoporosis, prior CVA with hemiplegia, depression, arthritis, and UTI. Her admission MDS showed moderately impaired cognition (BIMS 12), dependence in most ADLs and mobility, and a history of verbal behavioral symptoms such as screaming and cursing. Facility policy on change in condition required assessment, completion of SBAR, and timely physician notification for changes in physical or mental status.

On multiple occasions, nursing notes documented that the resident was yelling and making threats to throw herself on the floor or out of bed and out of her wheelchair, and repeatedly stating she did not want to remain in the facility and wanted to call 911. On one date, an LVN documented that the resident was yelling and threatened to throw herself on the floor. Later that same day, another LVN documented that the resident continuously yelled and screamed throughout the shift, repeatedly stating her intent to throw herself out of bed and out of her wheelchair, expressing a desire to go home, and wanting to call 911. On a later date, another LVN documented that the resident was again making threats to throw herself on the floor and yelling. These behaviors represented a change in mental/psychosocial status and included explicit threats of self-harm.

Despite these documented threats and behavioral changes, the involved LVNs acknowledged in interviews that they did not notify the physician or NP of the resident’s threats to hurt herself or her increased anxiety and agitation. They also acknowledged they had been trained to immediately report such threats to the physician or NP but did not provide a reason for failing to do so. The Medical Director, who was also the attending physician, confirmed that nursing staff had not reported the resident’s anxiety and threats to throw herself on the floor on the identified dates and stated he expected immediate notification when residents voiced threats to hurt themselves so that the situation could be evaluated. The DON and ADON similarly stated that nurses had been trained to immediately report such threats, but the notifications did not occur as required by facility policy and physician expectations.

Subsequently, the resident was found on the floor next to her bed by an LVN, who reported that the resident stated she had been leaning forward in her wheelchair to reach her call light and fell, and that she promised she did not throw herself on purpose. The call light was documented as clipped to the resident’s gown within reach. The resident complained of pain and requested transfer to the hospital, and the POA requested hospital transfer. The DON and ADON reported that the LVN who found the resident on the floor did not inform them that the resident had previously threatened to throw herself from the wheelchair. The Medical Director and facility leadership confirmed that they had not been notified of the earlier threats and behavioral changes, which constituted a failure to follow the facility’s change in condition communication policy and to immediately consult with the physician/NP when the resident experienced a significant change in mental status and voiced threats of self-harm.