F0684

G

Failure to Monitor and Document Suicidal Ideation per Physician Order

Broken Arrow, Oklahoma Survey Completed on 03-11-2026

Penalty

Fine: $12,735

Summary

The deficiency involves the facility’s failure to monitor and document a resident’s behavior according to a physician’s order following suicidal ideation. The resident had a history of depression, with an admission assessment showing a depression score of 8 indicating mild depression and intact cognition, and was receiving multiple psychotropic and pain medications, including Oxycodone for pain and various antidepressants and dementia medications. On the day of the incident, the suicide hotline notified the facility that the resident had called, reported feeling isolated, and was contemplating ending their life, disclosing that they were hoarding acetaminophen with the intent to use it for self-harm. The ADON documented this contact and noted that an order for behavior monitoring was put into place, including monitoring episodes of sadness, suicidal tendencies, suicidal thoughts, and agitation, with documentation of all findings and immediate provider notification.

Despite the physician’s order for behavior monitoring, the facility was unable to produce behavior monitoring documentation for this resident. The administrator later stated they were unable to find any behavior monitoring documentation, even though an order had been transcribed to monitor the resident’s mood and suicidal tendencies starting that evening. The facility’s own Suicide Threats policy required staff to monitor the resident’s mood and behavior and document details of the situation objectively in the medical record until a physician determined that suicide risk was no longer present. However, the record review and interviews did not show evidence that such ongoing monitoring and documentation occurred after the order was initiated.

Following the initial suicide hotline call, staff actions focused on immediate assessment, removal of bedside medication by instructing the family to take it home, and arranging for a bed bath and potential activity changes, but there is no documented pattern of behavior monitoring as ordered. Later that same evening, the suicide hotline called again, and an LPN assessed the resident, who stated they were fine and declined hospital evaluation. Shortly afterward, the roommate reported that the resident was shaking a pill bottle and threatening to take all the pills; the LPN then found the resident with an empty pill bottle, and 911 was called for hospital transport. Interviews with the administrator confirmed that behavior monitoring documentation could not be located, supporting the finding that the facility failed to ensure the resident’s behavior was monitored and documented in accordance with the physician’s order and facility policy.

The resident’s family members reported that the resident had been in significant, chronic pain, was very depressed, and had previously expressed thoughts about not wanting to live that way, although they were unsure whether the facility knew of this past suicidal ideation. Staff interviews indicated that the ADON believed the situation was resolved after the initial assessment and education about removing medications from the room, and that they relied on the family member to remove the acetaminophen. CNA and family interviews confirmed that a bottle of Tylenol or aspirin remained at the bedside and that the family member forgot to take it home. These accounts, combined with the absence of documented behavior monitoring after the suicide hotline notifications and the physician’s order, form the basis of the cited deficiency for failure to provide treatment and care according to orders and the resident’s needs.