F0656

J

Failure to Develop and Implement Comprehensive Care Plan for Resident With Suicidal Ideation

Dallas, Texas Survey Completed on 01-21-2026

Penalty

Fine: $45,705

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.