Failure to Develop Comprehensive Care Plans for Suicidal Ideation and Food-Seeking Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive care plans with measurable interventions to address identified medical, mental, and psychosocial needs for two residents. For the first resident, who was admitted with diagnoses including acute kidney failure, anxiety, depression, and a history of suicidal ideation, the clinical record showed multiple episodes of self-harm risk and destructive behaviors. These included climbing out a window after removing safety brackets and a screen, repeatedly reporting suicidal thoughts and passive death ideation with statements about stabbing herself or overdosing, removing a Wander Guard bracelet while on 1:1 observation, and exhibiting agitation, mood changes, and accusatory statements toward staff and a roommate. Staff also documented that this resident obtained two metal butter knives and attempted to insert them into an electrical outlet while on 1:1 observation. Despite these documented behaviors and mental health concerns, the resident’s care plan did not address her passive death/suicidal ideation or destructive behaviors, and did not include specific interventions for those behaviors, as confirmed by the Director of Nursing. The second resident had diagnoses including dysphagia, schizophrenia, and dementia, and exhibited repeated food-seeking behaviors and choking episodes that were documented over several months. Nursing notes described the resident coughing after taking and eating a half sandwich from another resident’s plate, being found on the floor turning blue and coughing up a semi-chewed peanut butter sandwich, and having a history of rummaging and taking food from trash cans and pudding from medication carts. The physician ordered a pureed diet and later a sippy cup with encouragement to drink slowly, yet staff continued to document episodes of the resident drinking too quickly and coughing, eating a peanut butter and jelly sandwich and coughing up unchewed pieces, and repeatedly seeking food and fluids, including taking pudding from the med cart, pacing and begging for food and water, and attempting to take water from another resident, which led to a physical altercation. Psychiatry also noted ongoing food-focused behaviors and taking items off carts. The care plan did not address the resident’s food-seeking behaviors or include specific interventions for those behaviors until after a choking incident in the dining room, a delay confirmed by the Director of Nursing.
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