F0742

G

Failure to Implement Behavioral Health Care Plan and Maintain Safe Environment for Suicidal Resident

Salisbury, Missouri Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate behavioral health treatment and services to a resident with serious mental illness, a history of trauma, and known coping mechanisms, resulting in multiple self-harm incidents. The resident had diagnoses including schizoaffective disorder, mood disorder, ADHD, PTSD, opioid abuse, anxiety disorder, and insomnia, with a documented history of severe bullying, sibling suicide, homelessness, substance abuse, and the death of a child. The PASRR and care plan identified the need for a low-stimulation environment, consistent routines, psychotherapy, ongoing psychiatric care, and person-centered, trauma-informed interventions. The care plan also directed staff to monitor for anxiety, avoid power struggles, provide opportunities for healthy energy release, and use non-invasive coping mechanisms before behavioral outbursts. Staff were aware that the resident’s coping mechanisms included watching calming television programs (especially Animal Planet), gaming, music, and writing in notebooks.

On one occasion, the resident’s guardian reported that the resident had voiced self-harm ideations, after which the resident was placed on one-on-one supervision and staff were instructed to search the room and remove harmful objects. Items with cords, including the television, gaming system, power cords, shoelaces, and hoodies with strings, were removed from the room. Two days later, while on one-on-one observation, the resident repeatedly requested the return of the television to watch Animal Planet, a known coping mechanism, and repeatedly asked to see the Environmental Services Supervisor to help get the television back. The one-on-one staff member assigned that day had never previously provided one-on-one observation and understood their role as only to prevent the resident from hurting self or others. The staff member did not provide additional interventions or access to the television, and the Social Services Designee later stated there was no reason to keep the television and personal items from the resident while on one-on-one observation and was not aware of the resident’s repeated requests or escalating distress.

As the resident’s requests for the television went unmet and the Environmental Services Supervisor was unavailable, the resident became increasingly agitated, knocked over linen carts, threw items in the hallway, and then went to the room and broke the inside pane of the double-pane window. The resident sat on the bed surrounded by glass, picked up a shard, and cut the left forearm from elbow to wrist, requiring emergency transport for medical and psychiatric evaluation. After the resident’s return from the hospital, staff failed to ensure the room was free of remaining glass shards. The resident later found glass in the windowsill and under the bed on separate occasions, cutting the same forearm multiple times while alone in the room. Staff documentation and interviews confirmed that shards remained in the windowsill and curtain area and that the room had not been thoroughly cleared of glass before the resident’s return. Although the care plan was updated to include high suicide risk and the need for a written safety plan and specific self-harm interventions, the record showed no evidence that staff collaborated with the resident to develop the written safety plan as directed. These actions and inactions demonstrate the facility’s failure to implement care-planned, person-centered behavioral health interventions, to maintain a safe environment free of known hazards, and to provide necessary services to support the resident’s highest practicable mental and psychosocial well-being.

The deficiency is further supported by staff and resident interviews describing the mismatch between the resident’s identified needs and the care actually provided. Staff acknowledged that the resident’s coping mechanisms included watching calming animal shows and gaming, and that removal of personal items, including the television, increased the resident’s agitation. The resident reported feeling that staff had taken away all coping mechanisms, leaving nothing to do while on one-on-one observation, and stated that close proximity and talkative staff increased anxiety. The resident described breaking the window with a metal cup, cutting the left forearm to obtain transfer to the hospital, and later intentionally searching the windowsill and under the bed for glass shards to cut the arm again. The Social Services Designee confirmed that glass shards from the initial incident remained in the room and that staff did not thoroughly clean the room before the resident’s return. Additionally, although the care plan called for development of a written safety plan and teaching alternative coping skills, the record contained no documentation that such a written safety plan was created with the resident, indicating a failure to implement the care-planned intervention for managing self-directed violence risk.