Failure to Investigate and Respond to Resident’s Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to investigate and respond to a resident’s verbalization of suicidal ideation as required by the resident’s care plan and facility policy. The resident had diagnoses of Alzheimer’s disease, anxiety, and depression, and a current MDS showed significant cognitive impairment with a BIMS score of 4. The resident’s care plan for depression with a history of suicidal ideation directed staff to immediately notify a supervisor and redirect the resident when suicidal comments were made. On 3/9/2026, a progress note documented that the resident told a volunteer she had nothing to live for and wanted to kill herself, and a 1:1 visit log from that same encounter recorded the same statement. However, there were no additional progress notes or documentation showing that the suicidal ideation was further assessed, that the care plan interventions were implemented, or that the provider was notified. Interviews revealed multiple communication and follow-through failures. The DON stated that any resident verbalizing suicidal ideation should be asked if they had a plan to harm themselves, the care plan should be reviewed and followed, and the resident might be sent for inpatient psychiatric care if appropriate. A QMA who regularly worked on the resident’s unit reported she was not aware of the suicidal statement made on 3/9/2026, although she recalled the resident had made suicidal remarks upon admission months earlier. The Life Enrichment Specialist stated that volunteers complete visit logs and that she entered the 3/9/2026 log into the computer on 3/18/2026, at which time she read the suicidal statement but did not report it as she should have. The volunteer reported that after hearing the suicidal statement, he offered supportive words and then reported it to staff on an adjacent unit when he could not immediately find the unit nurse. The facility’s “Suicide Threats” policy required immediate reporting of any suicide threats to the Nurse Supervisor, continuous supervision of the resident, completion of a Columbia Suicide Severity Rating Scale, reporting findings to the provider, following any provider orders, and documenting the situation, but these steps were not carried out for this resident’s suicidal verbalization.
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