F0689

J

Failure to Control Razor Access and Supervise Suicidal Resident

San Antonio, Texas Survey Completed on 02-13-2026

Penalty

Fine: $22,320

Summary

The deficiency involves the facility’s failure to maintain a resident environment as free of accident hazards as possible and to provide adequate supervision to prevent accidents for one resident with depression, anxiety disorder, and mild to moderate cognitive impairment. The resident was admitted with diagnoses including mild cognitive impairment, depression, and anxiety disorder, and her admission MDS showed a BIMS score of 8/15, indicating moderate cognitive impairment. She was ambulatory and required partial/moderate assistance for personal hygiene, including shaving. Her medication regimen included Buspirone for anxiety and Sertraline for depression, and her mood assessment reflected minimal depression. The care plan dated 2/6/2026 identified that the resident wanted to end her life and included interventions such as notifying the physician, counseling by social work and staff, refocusing to positive topics, psychological consult, and emergency room evaluation and treatment, but it did not mention a history of suicidal ideation.

On 2/4/2026, during the dinner period, the resident told a CNA that she wanted to kill herself and did not want to be there anymore. CNA C reported this statement to LVN B, and CNA A stayed with the resident while this was reported. Despite the resident’s suicidal statement, CNA A had previously provided the resident with two shaving razors so she could shave her legs and did not supervise her use of the razors, contrary to facility policy that residents are not supposed to have sharp objects and that staff must stay with residents who use shavers and dispose of them in sharps containers after use. Staff interviews later confirmed that residents were not to be left alone with razors and that razors were to be supervised and then discarded by staff. The facility’s suicide-threat policy required that suicide threats be taken seriously, immediately reported to the nurse supervisor or charge nurse, the physician be notified, and that a staff member remain 1:1 with the resident until the immediate danger had changed.

On 2/5/2026, the resident was discovered with a razor in her hand and a superficial scratch on her left wrist after having expressed multiple times that she wanted to harm herself. Documentation indicated that she had suicidal ideation, had voiced wanting to kill herself in the dining room, and then gone to her room. The transfer form and SBAR documented suicidal ideation and a superficial scrape to the left wrist, and that she was sent out for evaluation of suicidal thoughts. The resident later stated in an interview that she had asked a CNA for a razor to shave her legs and received two shavers with no supervision, that she was upset because a male resident had broken her heart, and that she did scratch herself due to a broken heart. The administrator and ADON reported that the resident had been provided two razor blades by CNA A and that staff were supposed to stay with residents using shavers and ensure no sharp objects were left with residents. The surveyors determined that the facility failed to ensure the resident’s environment was free of hazards and that she was adequately monitored, resulting in an Immediate Jeopardy situation beginning on 2/4/2026 and ending on 2/8/2026.

The noncompliance was identified as Past Noncompliance (PNC) at the Immediate Jeopardy level. The report states that this failure could result in residents experiencing suicidal ideations being at risk for harm, injuries, and death.

Removal Plan

• Revised Resident #1's comprehensive care plan to address statements and actions indicating she wanted to end her life
• Placed Resident #1 on 1:1 supervision until EMS arrived
• Notified the physician and Resident #1's responsible party/family
• Social worker met with Resident #1
• Referred Resident #1 to psychological services
• Ordered a urine test for Resident #1
• Sent Resident #1 to the emergency room for evaluation and treatment
• Suspended CNA A pending investigation and disciplined the employee
• Submitted a self-report of the incident to HHSC
• Assessed other residents in the facility for suicidal ideations
• Removed sharp objects/razors from resident rooms and bathrooms
• Conducted a facility-wide sweep to ensure no razors or sharp objects were present to ensure resident safety
• In-serviced all staff on Abuse/Neglect and Exploitation
• In-serviced all direct care staff on Razors
• In-serviced all staff on Suicidal Ideation
• Ensured staff who had not received the required education were not allowed to work until in-services were provided
• Discussed the incident involving Resident #1 with QAPI and during Adhoc meetings