Failure to Adequately Supervise and Monitor Suicidal Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise and monitor a resident after suicide attempts, and failure to follow its Suicide Prevention Guidelines policy. The resident was admitted with schizoaffective disorder, bipolar type, cognitive communication deficit, anxiety disorder, and major depressive disorder, and had a BIMS score of 14, indicating cognitively intact status. The resident required a Foley catheter for urinary retention. On one day in March, the resident attempted to commit suicide in her room by wrapping her call light cord around her neck. Staff removed the call light and other cords from the room, but there was no clear assignment or confirmation of continuous supervision at that time. Later that same day, the resident made a second suicide attempt by removing her Foley catheter and wrapping the tubing around her neck. CNA 1 reported first finding the resident with the call light around her neck and then, about 10 minutes after leaving the room at the request of nursing staff, finding the resident again with the Foley catheter around her neck while no staff were present. LVN 1 confirmed she knew the resident was a danger to herself and needed monitoring, but she left the room after the first attempt assuming that either RN 1 or CNA 1 would stay with the resident, and did not obtain confirmation of who would supervise. The DON later stated she was not aware that the resident had made two separate suicide attempts that day and believed the call light and Foley catheter were used at the same time. Following these events, the resident was placed on every 30‑minute visual checks rather than one‑to‑one monitoring. LVN 2, who worked the night shift after the attempts, stated the resident was on 30‑minute checks and questioned why one‑to‑one monitoring was not implemented given the suicide attempts. The DON stated the resident was not placed on one‑to‑one monitoring until two days after the attempts. Review of the facility’s Observation of Resident: Suicidal Ideation/Suicidal Attempts documentation showed that on a later date, the resident, who was ordered to be monitored every 30 minutes, was not monitored at 11:00 a.m., 3:00 p.m., and 3:30 p.m. The DON acknowledged the resident should have been monitored at those times. The facility’s Suicide Prevention Guidelines policy required immediate attention, close monitoring, and 30‑minute checks with documentation and room inspection when residents threaten or attempt self‑harm, but the monitoring ordered and the documentation of checks were not consistently carried out as required.
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