F0689

D

Failure to Implement Immediate Safety Measures After Resident’s Suicidal Statements 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 provide adequate supervision and maintain an environment free of potential hazards after a resident made suicidal statements and engaged in self-harm. 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. The care plan noted antidepressant use for depression and directed staff to monitor and report adverse reactions such as social isolation and suicidal thoughts.

On the evening in question, after dinner, staff observed the resident with a small screwdriver in hand and a cut on the back of his left hand. The resident stated he wanted to kill himself and refused to relinquish the screwdriver, threatening to harm anyone who tried to take it. A CNA notified the floor nurse (an LPN), who came to the unit and confirmed the resident’s suicidal statements and self-inflicted injury. The LPN contacted the resident’s family, who arrived and were eventually able to get the screwdriver from the resident and help calm him. During this time, the resident remained in the common area with the screwdriver while staff attempted to deescalate the situation. The family member later reported that when she left around late evening, the resident was not on one-to-one observation and she was not informed of any specific safety measures in place.

Multiple staff interviews and record reviews showed that no immediate safety interventions, such as initiating 15-minute checks or removing hazardous items from the resident’s room, were implemented the night of the incident. The LPN who managed the event did not notify management or the DON on call, and acknowledged that no safety measures were put in place until the following day. The oncoming night-shift LPN was told only that the resident had been upset and made a suicidal statement, and was not informed about the screwdriver or self-inflicted injury. The overnight CNA was not instructed to perform 15-minute checks and instead checked on the resident only as often as she could. Staff working the following morning, including the day-shift LPN and the social worker, learned of the suicidal incident only by reading the 24- or 72-hour reports, and both reported that no safety precautions were in place when they started their shifts. The DON later confirmed she was not informed until the next morning and acknowledged there was a delay in implementing protective steps, and both the DON and Administrator stated the facility did not have a policy on self-harm or suicidal ideation, relying instead on “standard practice of care.”

The deficiency is further supported by documentation that 15-minute checks were not started until the late morning of the day after the incident, despite the resident’s explicit suicidal statements and self-harm the previous evening. Staff interviews indicated that in a prior episode months earlier, when the resident made verbal comments about wanting to hurt himself, 15-minute checks had been initiated immediately, contrasting with the lack of timely action in this event. The delay in removing hazardous items from the resident’s room and the absence of immediate, structured monitoring following the suicidal statements and self-inflicted injury demonstrate that the facility did not ensure an environment free from accident hazards or provide adequate supervision to prevent further accidents for this resident.

The Administrator and DON both acknowledged that there was no specific facility policy addressing suicidal ideation or self-harm, and that staff were expected to follow a general standard practice that included immediate notification of management, physician contact, initiation of 15-minute checks, and removal of potentially harmful items. However, these expected steps were not carried out at the time of the incident. The lack of timely communication among nursing staff, failure to promptly notify the DON, and failure to implement enhanced supervision and environmental safety measures after the resident’s suicidal statements and self-harm directly contributed to the deficiency.