F0657

D

Failure to Update Care Plan for Suicidal Ideation and Self-Harm

West Des Moines, Iowa Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan to address suicidal ideation and self-harm behaviors, despite clear documentation of such behaviors in the clinical record. The resident had severe cognitive impairment, with a BIMS score of 2, and diagnoses including non-Alzheimer’s dementia and depression. The MDS documented that the resident’s behavior status had worsened compared to the prior assessment and that the resident sometimes felt lonely or isolated. Progress notes showed that on one occasion the resident became upset about being unable to leave, stated on a speakerphone call with family that he would kill himself, and was subsequently placed on 15-minute checks after the PCP was notified. The PCP advised continuing 15-minute checks and considering psychiatric follow-up for depression if the family allowed.

A later progress note documented that at bedtime the resident picked up a screwdriver and inflicted a small skin tear on the back of his left hand, stating he wanted to kill himself, refused to relinquish the screwdriver, and threatened to harm anyone who tried to take it, while staff attempted to deescalate the situation. Despite these documented suicidal statements, ideations, and a self-harm incident, the resident’s care plan did not include a focus area, goals, or interventions related to suicidal ideation or self-harm. The Kardex used by staff on the household also lacked any information or interventions related to these behaviors. During interviews, the DON and the Administrator both acknowledged that the care plan was not updated after the suicidal statements and self-harm incident, even though facility policy required the comprehensive care plan to be reviewed and revised with significant changes in condition and as needed.