Failure to Develop Suicide-Specific Safety Care Plan After Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a care plan focused on safety and monitoring for a resident who expressed suicidal ideation. The resident was admitted with diagnoses including malnutrition, difficulty walking, muscle weakness, and repeated falls, and had little to no cognitive impairment per the MDS dated 2/09/26. On 2/12/26, a mobile crisis team evaluated the resident after he made depressive and suicidal statements, reporting dissatisfaction with facility food, feelings of weakness, hearing problems, and a desire for hospice care. The county mental health note documented that the resident had made suicidal statements and that staff worked with him on meeting some of his needs. On 2/16/26, the resident was found on the floor after a fall and was sent to a general acute care hospital (GACH). The GACH history and physical documented that the resident was passively suicidal and had stated he did not like living at the facility and would kill himself if he returned. The GACH discharge summary later indicated there was no suicidal ideation at discharge and that shared decision making supported his return. The resident was readmitted to the facility on 2/18/26. On 2/19/26, he was found unresponsive and without vital signs on the bathroom commode, with copious amounts of blood on and around him and a toenail cutting tool nearby; his official time of death was documented as 7:20 a.m. Interviews and record review showed that no care plan addressing suicidal ideation or self-harm safety was initiated for the resident after his suicidal statements and evaluations. The DON stated that residents with suicidal ideation were typically transferred to the hospital for psychological screening and that, if they remained in the facility, staff would implement safety measures such as removing call light cords and sharp objects and providing one-to-one supervision, and that she expected social services to initiate a suicidal ideation care plan or coordinate with nursing to do so. The administrator stated that the social service director should have started a suicidal ideation safety care plan when the resident first complained of suicidal thoughts. An occupational therapy assistant reported that the resident had said, “It’s hospice or suicide,” and that she informed social services and a nurse. Facility policies on Behavioral Health Services and Suicide Prevention required comprehensive assessment, care plan development and implementation, immediate reporting of suicidal ideation, not leaving the resident alone, and documentation of mood, behaviors, and actions taken, but these were not reflected in a suicidal ideation or self-harm safety care plan for this resident.
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