Failure to Provide Necessary Behavioral Health Services to Suicidal Resident
Summary
The deficiency involves the facility’s failure to ensure a resident with significant behavioral health needs received necessary behavioral health care and services in accordance with her assessment and care plan. The resident was an older female with bipolar disorder, recurrent major depressive disorder with psychotic symptoms, 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 depressive symptoms several days in the prior two weeks. Her care plan identified depression related to a family member’s death, lack of closure, perceived lack of money, limited family visits, and feeling confined to her room, with signs including poor appetite, trouble sleeping at night, and sleeping in. The care plan also documented suicidal ideations and interventions such as listening, providing comfort, and communication to promote mental and psychological well-being, with the social worker identified as her mental health professional. The resident had a history of suicidal behavior and ideation while at the facility. Progress notes documented that on one occasion she wrapped a draw sheet around her neck, stated she wanted to die and join her deceased family member, and an order was obtained to keep a close eye on her every 15 minutes. On another occasion, she approached a nurse 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 to cut herself, and she was transported to a hospital. The care plan reflected prior hospitalizations at behavioral health facilities, and interviews with the DON, Administrator, and family confirmed multiple inpatient behavioral health stays and a prior suicide attempt at the facility involving a bedsheet around her neck. Despite this history, record review of the electronic health record on the date of her death showed no evidence that she was receiving behavioral health services at the time of her suicide. In the period leading up to the fatal event, staff continued to observe depressive symptoms and suicidal ideations. A social worker note documented that the resident stated she wanted to die, felt she was a disappointment, did not want to do anything, and did not want to eat, though she denied a plan and said she would not harm herself; the physician was notified, and the resident had a private caregiver with her daily from 2:00 PM to 4:00 PM. An LVN reported that for months after the resident’s third behavioral health facility stay, the resident continued to express suicidal ideations, slept all day, and often said she was sad; the LVN stated she reported these ongoing suicidal ideations to the medical director and DON, but the resident was not sent back to a behavioral health center. The facility instead increased activities and relied on counseling by the social worker, although the social worker reported that for the last six months the resident refused to speak with her and was not seeing another therapist. On the day before the resident’s death, an LVN documented that the resident produced an unopened bottle of diphenhydramine (Benadryl) from her drawer, and the nurse locked it in the medication cabinet and administered a provider-ordered dose; the next morning the resident was found unresponsive with pink emesis and two diphenhydramine bottles at the bedside, one almost empty, and hospital records indicated concern for an intentional overdose. Interviews and record review confirmed that, at the time of this lethal ingestion, the resident was not receiving behavioral health services despite her ongoing suicidal ideations and documented history of depression and prior suicide attempts. The facility’s own suicide threats policy required immediate reporting of suicide threats to a licensed nurse, leadership, and campus dispatch, continuous staff presence with the resident until a licensed nurse or provider arrived, and interdisciplinary assessment and care plan revision after such incidents. While some prior suicidal episodes resulted in hospital transfers and temporary 1:1 sitters, the ongoing expressions of suicidal ideation over several months after the last behavioral health discharge were not accompanied by documented behavioral health services or further inpatient evaluation. Staff interviews revealed that personal sitters and CNAs were aware of the resident’s depression and sleep patterns but did not consistently report suicidal ideations to the social worker, who stated she was not informed of continued suicidal ideations. The combination of a known history of suicide attempts, repeated suicidal statements, refusal of counseling, and lack of active behavioral health services at the time of the event formed the basis of the deficiency, culminating in the resident’s ingestion of a lethal dose of diphenhydramine and subsequent death.
Removal Plan
- Staff initiated emergency response procedures when Resident #1 was found vomiting and convulsing with an almost empty bottle of Benadryl at bedside.
- Nursing staff completed a 100% room sweep of all skilled nursing residents' rooms to ensure no outside or unauthorized medications were present in residents' rooms.
- Send a communication to all family members of skilled nursing regarding the facility medication policy for outside medications and send monthly for the next three months.
- Add communication on the facility policy for outside medications to the admission packet for all new residents.
- Director of Nursing initiated interviews with all staff that cared for Resident #1 in the past week to confirm whether any signs or changes in resident mood or suicidal ideations were observed.
- Reinforce that suicide threats are to be taken seriously and immediately reported to the licensed nurse, clinical leaders, campus dispatch and/or administration.
- Staff must immediately report suicidal threats to the licensed nurse.
- The licensed nurse must immediately notify CC Leadership on Call and campus dispatch.
- Administration/nursing administration with the medical provider will determine appropriate interventions including potential 1:1 supervision and potential need for emergency/acute care evaluation/treatment.
- The interdisciplinary team will assess actions/expressions as soon as possible to determine needed interventions and revise care/service plans.
- Documentation must be recorded in the medical record and an incident report completed.
- Director of Nursing or designees will conduct wellness interviews of all interviewable residents using PHQ-9 questions #1, #2, and #9 to assess for immediate signs of depression, depression symptoms, and/or thoughts of self-harm.
- Residents with concerning responses will have appropriate interventions implemented immediately including provider notification and psychiatric referral.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to address a resident’s alcohol use and substance use disorder concerns. A cognitively intact resident with stroke, malnutrition, a G-tube, and an NPO diet was observed with signs of intoxication, and staff found alcohol in the room and documented that the resident admitted sneaking alcohol into the facility daily. The care plan did not include the resident’s alcohol use or any interventions, and multiple staff reported there were no documented interventions related to monitoring for intoxication or substance use.
A resident with schizoaffective disorder, PTSD, depression, anxiety, and an intellectual disability repeatedly manipulated his colostomy bag and ate feces, while staff also observed him adding excessive salt to food and becoming tearful or aggressive when redirected. The care plan did not address the feces-eating behavior, trauma history, or triggers, and social services did not follow through on a physician’s guardianship recommendation. The resident later developed nausea, hypoxia, and respiratory distress, and hospital records showed pneumonia likely related to aspiration.
Failure to Provide Behavioral Health Care for Resident Grief: A resident with Lewy body dementia and severe cognitive impairment developed grief-related behaviors after learning of her sister’s death, including yelling at staff and attempting to hit staff. The record contained only a RD note linking poor intake to grief, with no social work or psych notes and no care plan addressing grief or the resident’s psychosocial symptoms.
Failure to Manage Unsafe Behaviors and Behavioral Health Needs: A resident with dementia, schizophrenia, and a history of fire-setting repeatedly smoked in undesignated areas and in the building, while another resident with mood disorder, nicotine dependence, and TBI repeatedly smoked in the room and bathroom and kept smoking paraphernalia in the room. The facility also failed to monitor residents with elopement risk, allowing one resident to wander unsupervised and elope, another to leave the building unsupervised multiple times and nearly be struck by a vehicle, and a third resident with a history of aggression to physically assault other residents.
Failure to Identify and Monitor Behavioral Health Needs Related to Substance Use: The facility did not adequately assess or monitor residents with known SUD histories and recent signs of relapse. A resident with opioid withdrawal, fentanyl use disorder, and polysubstance use disorder showed erratic behavior, withdrawal signs, and self-injury, while staff documented concerns but did not clearly communicate withdrawal from illegal drugs to the physician. Another resident with psychoactive substance abuse was found unresponsive with labored respirations, required Narcan and CPR, and was later on a Narcan drip. The record also showed narcotics found in a resident’s purse and room, with police involvement after the resident admitted recent fentanyl and methamphetamine use.
Failure to Individualize Behavioral Health Care Plan: A resident with agitation, verbal aggression, and loud outbursts had repeated behavioral issues documented in psych, psychosocial, and nursing notes, including distress when needs were not met right away. The care plan did not address his behaviors, cultural background from Honduras, preferences, or refusal of outside psychiatric services, and the ADM and DON confirmed these items were not care planned.
Failure to Address Resident Alcohol Use and Substance Use Disorder
Penalty
Summary
The facility failed to implement interventions related to substance use disorder for a resident who was admitted with diagnoses including stroke and malnutrition and who was receiving tube feeding through a gastrostomy tube with a current NPO diet order. The resident had a BIMS of 15 and was cognitively intact. On 4/14/26, an RN observed the resident ambulating with an unsteady gait, red/glossy eyes, increased drooling from baseline, and an odor of alcohol, and found a bottle of whiskey that was about 60% gone in the resident’s room. The resident admitted to sneaking alcohol every day since admission and refused transfer to the hospital for further evaluation, so hourly monitoring was initiated. A physician progress note on 4/15/26 documented that the resident admitted being an alcoholic and sneaking alcohol into the facility daily despite the NPO order and facility policies, and the risks of aspiration were reviewed. The care plan contained no information related to the resident’s noncompliance with the NPO diet order and alcohol consumption, and no interventions were implemented, including monitoring for signs and symptoms of substance use disorder. Multiple staff members later stated they found empty alcohol containers or observed signs consistent with alcohol use, but reported there were no interventions in place related to the resident’s alcohol use, and the DNS acknowledged the medical record needed to include interventions such as signs and symptoms of intoxication.
Failure to Address Recurrent Coprophagia and Behavioral Health Needs
Penalty
Summary
The facility failed to facilitate guardianship and appropriate behavioral health services for a resident with schizoaffective disorder, PTSD, depression, anxiety, and an intellectual disability, while the resident continued to display behaviors that were detrimental to his psychosocial and physical well-being. The resident also had paraplegia, diabetes, chronic kidney disease, dysphagia, and a colostomy. Care plans addressed elimination needs and psychosocial/mood concerns, but the record did not include interventions for the resident opening his colostomy bag, eating feces, or what staff should do when that behavior was observed or suspected. The social services director confirmed there was no care plan mention of the resident’s trauma history or triggers and no evidence that a PASRR had been filed regarding his intellectual disability, psychiatric diagnoses, and acute respiratory illness with hypoxia. The record showed repeated episodes of the resident manipulating his colostomy bag and ingesting stool. A nurse documented witnessing the resident eating bowel movements from a leaking colostomy bag, and the resident became yelling and hit the nurse when educated. A provider note later described the behavior as consistent with pica and documented that staff had seen the behavior multiple times. Additional notes and staff interviews described the resident putting multiple salt packets into food, crying when redirected, picking at his colostomy bag, and eating his own scabs. Several staff members stated they had seen the resident eat feces or touch and lick stool from the colostomy bag, but some said they did not document the behavior or did not think it was a big deal. The resident’s behavior escalated to a hospital transfer after he was found to have gotten into his colostomy bag and eaten stool, followed by nausea, dry heaves, minimal intake, sudden hypoxia, tachycardia, sweating, and low-grade fever. Hospital records documented pneumonia, likely aspiration, and acute respiratory failure with hypoxia. The physician later noted the resident lacked decision-making capacity for surgery and recommended expediting guardianship, but the medical record contained no follow-up documentation related to that recommendation. Interviews also confirmed the social services director had not followed up on the guardianship request and did not know the resident’s triggers, while staff and providers described the resident as childlike, tearful, and unable to understand the impact of his behaviors.
Failure to Provide Behavioral Health Care for Resident Grief
Penalty
Summary
The facility failed to ensure that Resident 41 received necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being. Resident 41 was admitted with diagnoses including neurocognitive disorder with Lewy body dementia and was severely cognitively impaired on the Quarterly MDS, with a BIMS score of 3. The record showed that the resident experienced grief after learning of her sister’s death, and a roommate reported that Resident 41 had been exhibiting new behaviors, including attempting to hit staff and yelling at staff, related to that loss. The clinical record contained only one note addressing the resident’s loss, which was a nursing progress note by the Registered Dietician stating that the resident’s recent poor intake could potentially be related to grief. There was no documented evidence that behavioral health services were provided for the grief, no social service notes, no psychological services notes, and no care plan for grief. The resident’s care plan did not address the specific mental health concern or psychosocial symptoms, and the NHA was unable to provide evidence that Resident 41 was receiving psychological services to maintain the highest practicable level of mental and psychosocial well-being.
Failure to Manage Unsafe Behaviors and Provide Behavioral Health Services
Penalty
Summary
The facility failed to ensure behavioral health care and services were provided for residents with known unsafe behaviors, including unsafe smoking, wandering, elopement risk, and physical aggression toward other residents. The report states the facility did not implement a behavior management process to identify, evaluate, and address behaviors affecting resident safety, and did not recognize the need for adequate supervision and monitoring of residents with unsafe behaviors. The Immediate Jeopardy was cited under F740 Behavioral Health Services and was identified as beginning on 03/30/2024. Resident #33 had diagnoses including Dementia with Moderate Mood Disturbance, Insomnia due to other mental disorders, Mental Disorder NOS, and Paranoid Schizophrenia, and had a BIMS score of 15 of 15. The resident’s behavior management care plan addressed noncompliance with smoking and setting fires, with interventions including 1:1 supervision, re-education on smoking policy, observation and documentation of target behaviors, diversional activities, and behavior medications as ordered. Progress notes and staff interviews documented repeated unsafe smoking-related behaviors, including smoking in undesignated areas, smoking in the building, possession of cigarettes and lighters, and a history of starting fires. Staff described that when cigarettes or lighters were found, they were taken away, and the medical director stated she was aware of the smoking and aggression but not that the resident was a fire starter. Resident #109 had diagnoses including Mood Disorder due to Psychological Condition with Depressive Features, Paraplegia, Nicotine Dependence, and Personal History of Traumatic Brain Injury, and also had a BIMS score of 15 of 15. The resident was care planned for verbal behavioral symptoms, nicotine addiction, and smoking outside designated areas, with an approach to observe for need for 1:1 smoking supervision. Progress notes documented repeated smoking in the room and bathroom, strong cigarette odor, cigarette butts and smoking paraphernalia in the room, and marijuana odor in the room. Staff interviews confirmed that the resident continued to smoke in the room and that no new interventions were put in place beyond education on the smoking policy. Resident #106, who had a history of elopement risk, wandered the facility unsupervised during the day and at night and eloped on 04/14/2026 without the facility being aware. Resident #121, who had a history of elopement risk, noncompliance with care/treatment, and confusion, left the building unsupervised on 04/05/2026 and 04/10/2026, and eloped again on 04/11/2026, nearly being struck by an employee’s vehicle. The facility was aware of the earlier instances because the resident was allowed to leave unsupervised. The report also states the facility failed to manage Resident #116’s pattern of abusive behavior toward other residents, including swinging at, hitting, and pulling other residents to the floor when wheelchairs bumped into each other. Investigative files documented physically abusive incidents involving multiple residents on several dates, and the deficiency affected five sampled residents.
Failure to Identify and Monitor Behavioral Health Needs Related to Substance Use
Penalty
Summary
The facility failed to identify, assess, monitor, and address behavioral health needs related to substance use disorder for residents with known histories of substance abuse. The report states that the facility did not thoroughly review referral information that identified recent substance use and positive toxicology results, and it did not implement appropriate behavioral health interventions, monitoring, and services during a period when social services staff were unavailable. As a result, warning signs of relapse and ongoing substance use were not identified or addressed for Residents #104, #105, and #101. Resident #104 had a hospital history that included opioid withdrawal, fentanyl use disorder, and polysubstance use disorder. The resident’s psychosocial history listed substance abuse, increased anxiety, and a past history of suicidal ideations/attempts. The care plan identified risk for polysubstance abuse and overdose, with interventions to monitor for substance abuse, intoxication, withdrawal, and items brought into the facility. Progress notes described erratic behavior, signs of withdrawal, repeated sliding out of a wheelchair, and self-picking that caused a sore on the face. Staff documented that the resident refused clinical evaluation and a telehealth visit, and the physician was notified of behavior and refusal of care, but the notes did not show staff spoke with the physician specifically about withdrawal from illegal substances. Interviews showed staff believed the resident was withdrawing from street drugs, had a history of opioid abuse, and was later found with fentanyl, methamphetamine, and other substances in the resident’s purse and room. Resident #105 had diagnoses including other psychoactive substance abuse and homelessness. The resident experienced an acute change in condition and was found slumped over in a wheelchair, unresponsive, with labored and irregular respirations and oxygen saturation of 82% on 5 liters of oxygen. Narcan was administered twice, CPR was initiated, EMS transported the resident to the hospital, and the resident was later documented as being on a Narcan drip. The record also showed a care plan addressing overdose risk, substance-seeking behavior, monitoring for intoxication and withdrawal, and room checks. The report further described that Resident #104 and Resident #105 spent time together before the overdose event, and police later reported that Resident #104 admitted obtaining narcotics from an outside source and that narcotics were found in the resident’s room and purse.
Failure to Individualize Behavioral Health Care Plan
Penalty
Summary
The facility failed to develop an individualized behavioral health care plan to address one resident’s behavioral health needs. Resident #1’s psychiatric consult note documented increased agitation, verbal aggression when needs were not met right away, defensiveness and irritability during conversation, and statements about talking loudly so people would understand him. The note also recorded that he said he had been a slave in Honduras and did not like being disrespected or labeled as something he was not. Nursing notes documented multiple dates when behaviors were present, including an incident in which he was observed yelling in the hallway for a pillowcase and continued to yell and act irate even after staff promptly provided it. The resident’s psychosocial note also documented increased agitation when his needs or preferences were not met immediately. Review of the care plan showed no plan addressing his behaviors, cultural background and preferences, or refusal of outside services. Staff interviews confirmed he was verbally aggressive, difficult to calm when he did not get his way, and had loud outbursts when things did not go as he wanted. Social services and nursing staff stated he refused all therapeutic psychiatric services except the consulting psychiatric group, and the administrator and DON confirmed that his behaviors, cultural background, and refusal of services should have been care planned but were not.
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