Failure to Develop and Implement Comprehensive Care Plan for Resident With Suicidal Ideation
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and specific interventions to address a resident’s identified suicidal ideations and significant mental health history. The resident was an older female with bipolar disorder, recurrent major depressive disorder with psychotic symptoms, moderate vascular dementia with psychotic disturbance, anxiety disorder, and epilepsy. Her MDS showed a BIMS score of 14, indicating little to no cognitive impairment, and documented that she felt down, depressed, or hopeless on several days in the prior two weeks. The care plan noted prior behavioral health hospitalizations and that she would exhibit or express depression related to the death of a family member, lack of closure, financial concerns, limited family visits, and feeling confined to her room. Signs and symptoms of depression such as poor appetite and sleep disturbance were documented, and the care plan stated she would speak with the social worker if she needed counseling, identifying the social worker as her mental health professional. The resident’s care plan also documented that she had suicidal ideations, but the interventions listed were limited to listening and providing comfort when she was confused and agitated and communicating in a manner that promoted mental and psychological well-being. Despite multiple serious episodes indicating active suicidal ideation and behavior, the care plan was not revised to include more specific, measurable, and individualized interventions. Progress notes showed that on one occasion a CNA reported the resident had wrapped a draw sheet around her neck, stated she wanted to die and join her husband, and the MD ordered close observation every 15 minutes. On another occasion, the social worker documented that the resident stated she wanted to die, although she denied a plan and said she would not harm herself; the physician was notified and it was noted she had a caregiver with her for two hours daily. Later, the resident directly approached an LVN stating she was feeling suicidal, was looking for a bottle of pills to take, and did not care anymore; she also told police she would use a light bulb in her room to cut herself, leading to her being sent to the hospital. After these events, the care plan for suicidal ideation was not updated with detailed, resident-specific safety measures or clear, measurable objectives and timeframes. The DON stated that each department was responsible for its portion of the care plan, that the MDS coordinator was new and in training, and that there was no clinical manager for approximately two weeks, during which time he was responsible for care plans. The DON believed the existing interventions were appropriate and thought the resident was following them by attending activities and speaking with the social worker, so no additional interventions were added until after surveyor inquiry. The Administrator reported that the resident had been sent to behavioral health facilities multiple times and had previously been found with a bedsheet around her neck after a suicide pact with her husband, and that a 24-hour sitter had been reduced to two hours daily at the resident’s request. The Administrator and Medical Director both believed the resident had long-standing depression and had declined or refused some offered help, and the social worker reported that staff had not informed her of the resident’s continued suicidal ideations and that the resident had refused to speak with her for the last six months. Ultimately, EMS later found the resident unresponsive with an empty and a partially empty bottle of Benadryl at bedside, with multiple seizures en route to the hospital, and she was pronounced dead; family and EMS expressed concern that she may have intentionally overdosed, and surveyors determined that the facility had failed to develop and implement a comprehensive care plan with adequate, measurable interventions for her suicidal ideations.
Removal Plan
- Staff initiated emergency response procedures when Resident #1 was found vomiting and convulsing with an almost empty bottle of Benadryl at bedside.
- Director of Nursing initiated interviews with all staff who cared for Resident #1 to determine whether any signs or changes in mood or suicidal ideations were observed.
- Director of Nursing (or designee) will conduct wellness interviews of all interviewable residents using PHQ-9 questions #1, #2, and #9 to assess for depression symptoms and/or thoughts of self-harm; any concerning responses will trigger immediate interventions including provider notification, psychiatric referral, and care plan updates.
- Social worker (or designee) will visit residents with concerning PHQ-9 responses and reassess ongoing visit needs.
- Social worker/nursing will conduct wellness interviews of non-interviewable residents using PHQ-9 questions #1 and #2 (staff observation); any concerning responses will trigger immediate interventions including provider notification, psychiatric referral, and care plan updates.
- Regional Director of Clinical Operations completed a 100% audit of MDSs, confirming zero residents answered 'yes' to thoughts of being better off dead.
- Regional Director of Clinical Operations completed a 100% audit of MDSs with depressive symptoms.
- Director of Nursing (or designee) will conduct an audit of all current resident care plans to validate measurable objectives, timeframes, and interventions addressing mental health and psychosocial needs identified in the comprehensive assessment; discrepancies will be corrected promptly.
- Director of Health Services Education and Training will train the Staff Development Coordinator (and/or designee) on the policy for comprehensive person-centered care plans with measurable objectives, timeframes, and interventions addressing mental health needs.
- Staff Development Coordinator (and/or designee) will educate all leadership and licensed nurses on the facility policy for comprehensive person-centered care plans with measurable objectives, timeframes, and interventions addressing mental health needs; training will be documented on a Management Training Roster maintained by NHA/HR; retraining will occur annually.
- Employees not trained due to absence, schedule rotation, or other factors will be removed from the schedule until required training is completed and documented.
- Standard operating procedures for handling unauthorized outside medications and required actions if noted in resident rooms will be incorporated into ongoing new-hire orientation for all licensed nurses and nurse managers.
- Identified at-risk residents will be reviewed during clinical meeting to assess for changes in depressive symptoms and/or suicidal ideations.
- Social worker (or designee) will perform wellness interviews using PHQ-9 questions #1, #2, and #9 with a randomized sample of residents; any identified concern will trigger immediate interventions including provider notification, psychiatric referral, care plan updates, and safety measures.
- Social worker will conduct wellness interviews of non-interviewable residents using staff-observation PHQ-9 questions #1 and #2.
- Director of Nursing (or designee) will conduct an audit of all newly admitted residents to confirm PHQ-9 assessments were completed and appropriate care plan interventions were implemented.
- Director of Nursing (or designee) will audit all current resident care plans to validate measurable objectives, timeframes, and interventions addressing mental health and psychosocial needs; discrepancies will be corrected promptly.
- Director (or designee) will conduct an audit of all newly admitted residents to validate care plans include measurable objectives, timeframes, and interventions addressing mental health and psychosocial needs to prevent serious harm or death.
- Audit findings will be reviewed during QAPI meetings; additional audits and education will be determined based on findings.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, muscle weakness, and protein-calorie malnutrition had a care plan directing staff to offload his heels or use Prevalon boots while in bed. During observation, he was found in bed without the boots, and an LPN confirmed his heels were not offloaded even though they should have been.
Failure to care plan depression: A resident with MDD and ongoing depressive symptoms had psychology evaluations documenting depressed mood, loss of interest, sleep disturbance, fatigue, and appetite changes, and the MDS listed depression as an active dx. However, the care plan did not include depression as a focus area, and the MDS Coordinator and DON both stated it should have been care planned.
Incomplete care planning for ordered medications and diabetic footwear. The facility did not include ordered meds such as Eszopiclone, Lexapro, Mirtazapine, and Zolpidem in residents' comprehensive care plans, and one resident was not measured for diabetic shoes and insoles per MD order. The MDS Coordinator said the missing medication care plans were an oversight, while the DON and Administrator stated care plans are used to direct and guide resident care.
A facility failed to include person-centered comprehensive care plan focus areas for two residents receiving ordered meds. One resident with atrial fibrillation was receiving Eliquis, and another resident with insomnia was receiving Trazodone, but neither current care plan addressed the medication use. The MDS Nurse stated she was responsible for care plan development and said the omissions were due to oversight.
Failure to update a resident’s fall care plan with a Geri-chair intervention. A resident with dementia, osteoarthritis, diabetes, severe cognitive impairment, and a history of falls had a care plan listing multiple fall precautions, but after a witnessed fall and a physician order for a Geri-chair or tilt back WC, the care plan was not updated to include that intervention. Surveyors observed the resident in a Geri-chair, and the MDS Coordinator and DON acknowledged the care plan had not been updated.
Failure to care plan a resident’s impaired hearing. A resident with dementia and a history of hard of hearing was observed unable to hear normal conversation and stated he refused to use his hearing aid. The SSD and RN confirmed no care plan had been initiated for the hearing impairment or hearing aid refusal, and the DON stated the condition should have been care planned per facility policy and MDS triggers.
Failure to Offload Heels as Directed
Penalty
Summary
Resident #32, who was admitted with diagnoses including dementia, muscle weakness, and protein-calorie malnutrition, had a care plan revised on 6/18/21 directing staff to offload his heels or use Prevalon boots when he was in bed, as he allowed. During observation on 7/9/26 at 11:22 AM, Resident #32 was found in bed without Prevalon boots in place. At 11:23 AM, an LPN stated the resident should have had his boots on, then lifted the blanket and observed the resident's legs resting on a pillow. When asked whether the resident's heels were offloaded, the LPN stated they were not and confirmed they should have been offloaded.
Failure to Care Plan Depression
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #22, who had diagnoses including Major Depressive Disorder and was documented by psychology evaluations as having recurrent, moderate depression. The resident’s evaluation notes described decreased interest in activities, persistent depressed mood, sleep disturbances, fatigue, and changes in appetite, with symptoms occurring on more than half of the days and causing moderate subjective distress. A later psychology note again documented persistent depressed mood, marked loss of interest, altered sleep patterns, and fatigue with moderate distress. The resident’s quarterly MDS dated 6/13/2026 documented an active diagnosis of depression in Section I, but the care plan did not include a focus area for depression. During interview, the MDS Coordinator stated the resident had been followed by Balance Wellbeing since 12/2025, the diagnosis was entered on 5/20/2026, and depression was not included in the care plan but should be. The DON also stated the resident should be care planned for depression. The facility policy required a comprehensive person-centered care plan with measurable objectives and timeframes to meet the resident’s medical, nursing, and psychosocial needs and all services identified in the comprehensive assessment.
Incomplete Care Planning for Ordered Medications and Diabetic Footwear
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for 3 of 4 residents reviewed. Resident #12 had diagnoses including dementia, anxiety, malnutrition, and depression, and her physician orders included Eszopiclone for insomnia, Lexapro for depression, and Mirtazapine for protein-calorie malnutrition. Although these medications were active and administered, the comprehensive care plan dated 04/23/26 did not include care planning for Eszopiclone, Lexapro, or Mirtazapine. Resident #3 had diagnoses including PTSD, depression, and stroke, with a BIMS score of 08 indicating severely impaired cognition. Her physician order dated 06/01/26 included Zolpidem Tartrate 5 mg at bedtime for insomnia, and the MDS indicated she received a hypnotic medication during the look-back period. The comprehensive care plan did not indicate Zolpidem. During interview, the MDS Coordinator stated she reviewed the records and did not see care plans for Resident #12's medications or Resident #3's Zolpidem, and said it was an oversight. Resident #2 was also identified in the deficiency statement as not being measured for diabetic shoes and diabetic insoles per physician order. The facility's policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident and revised as conditions change. The DON and Administrator stated that care plans were a team effort and used to direct and guide resident care, and that if care plans were not done properly, care could be missed.
Missing Care Plan Focus Areas for Anticoagulant and Antidepressant Medication Use
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident receiving anticoagulant medication. Resident #5 was admitted with atrial fibrillation and had a physician order for Eliquis 5 mg by mouth twice daily. The June 2026 MAR showed the resident received Eliquis as ordered, and the quarterly MDS assessment coded the resident as moderately cognitively impaired and receiving anticoagulant medication. However, the resident’s current comprehensive care plan, last reviewed on 6/19/26, did not include a care plan focus area for anticoagulant medication use. The facility also failed to develop a person-centered comprehensive care plan for a resident receiving antidepressant medication. Resident #8 was admitted with insomnia and had a physician order for Trazodone 50 mg by mouth at bedtime. The June 2026 MAR showed the resident received Trazodone as ordered, and the quarterly MDS assessment coded the resident as cognitively intact and receiving antidepressant medication. The resident’s current comprehensive care plan, last reviewed on 6/18/26, did not include a care plan focus area for antidepressant medication use. In both cases, the MDS Nurse stated she was responsible for developing the care plans and identified the missing care plan areas as an oversight.
Failure to Update Fall Care Plan With Geri-Chair Intervention
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that included all of Resident #1’s fall interventions. Resident #1, a [AGE]-year-old female with dementia, osteoarthritis, and diabetes mellitus, had a quarterly MDS showing a BIMS score of three, indicating severe cognitive impairment, and was assessed as having falls with one fall without injury. Her comprehensive care plan identified her as being at risk for falls related to debility, advanced age, and behaviors, and included interventions such as a low bed with fall mat, tilt back wheelchair, staff education, correct positioning in chair, nonskid tape under the fall mat, use of a call light, monitoring for changes in condition, and a pommel cushion added to the chair. After Resident #1 experienced a witnessed fall from her wheelchair in the TV area, a physician order was entered for safety devices including a low bed, fall mat, and Geri-chair or tilt back wheelchair. At the time of survey observation, Resident #1 was seen in a Geri-chair in the TV area and stated she liked it and was comfortable in it. However, the care plan did not include the Geri-chair intervention. The MDS Coordinator stated she had seen Resident #1 in the Geri-chair but had not yet updated the care plan, and the DON stated whoever had the resident should have seen the order for the Geri-chair and updated the care plan.
Failure to Care Plan Hearing Impairment
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions to address Resident 33’s impaired hearing. Resident 33 was admitted with diagnoses including dementia, muscle weakness, and abnormal gait and mobility, and the H&P documented a history of hard of hearing. The MDS dated 6/5/2026 indicated the resident was moderately impaired in cognitive skills for daily decision making and had minimal difficulty hearing. During an observation and interview on 6/29/2026, Resident 33 was lying in bed and stated he could not hear the surveyor during a normal conversation, that he was hard of hearing, and that he refused to use his hearing aid. The SSD stated the resident had difficulty hearing, refused to use the hearing aid, and had no care plan initiated for impaired hearing. RN 2 later confirmed there was no care plan for the resident’s impaired hearing and that one should be in place to address the hearing impairment and refusal to use the hearing aid so staff could communicate effectively. The DON stated that a resident with impaired hearing should be care planned according to facility policy and that hearing impairment triggered on the MDS should be care planned, including refusal to use the hearing aid.
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