Failure to assess and monitor suicidal ideation
Summary
The facility failed to ensure a resident who had voiced suicidal ideations received a mental health evaluation, monitoring, and suicide precautions after multiple staff members documented or heard statements that he would be better off dead or would kill himself if he had the means. The resident was admitted after a fall with a non-operable left hip fracture, acute pain, and moderate protein-calorie malnutrition, and he had no mental health diagnoses on admission. His baseline care plan did not include goals or interventions for depression or mental health. He also had a history of opioid and fentanyl exposure and a blood alcohol level of 15 at the hospital, and the Medical Director later documented a long-term depression history and alcohol use. On the resident’s depression screening, the Social Worker documented that the resident said he would be better off dead because of the amount of pain he was experiencing, and the PHQ-9 score was 10, indicating moderate depression. The Social Worker did not notify administration, the Medical Director, or nursing, did not begin monitoring, and did not make a mental health referral. Two days later, therapy staff documented that the resident stated he would kill himself if he had the means. Therapy staff reported the statement to the Therapy Manager and a nurse, but the information was not escalated to administration, the Medical Director, or other leadership at that time. The Medical Director later saw the resident and documented that he was miserable, upset, distraught, and in severe pain, but the depression was deferred until pain was controlled. The resident’s suicidal statements were not communicated consistently across disciplines, and staff interviews showed that multiple nurses and aides were unaware of the earlier suicidal comments. The Social Worker later met with the resident after administration learned of the statement and reported that he was no longer suicidal, but no formal assessment or psychiatric referral was completed. On the evening of the incident, the resident was described as irritated and wanting to be left alone; he also asked for his phone to be unplugged and did not want to talk with family. Later that night, he was found unresponsive in bed with the bed control cord wrapped tightly around his neck, without breathing or a pulse. EMS determined the cardiac arrest was associated with intentional self-harm by hanging, and the death certificate listed the manner of death as suicide by self-strangulation with the bed control cord.
Penalty
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Below are regulatory guidelines relevant to this citation:
Failure to Address Behavioral and Psychosocial Needs: A resident with ESRD and a traumatic amputation had verbal outbursts, cursing, and derogatory language toward staff, but was not referred for behavioral health or grief counseling after his son’s death. The resident missed dialysis treatments because of behavior and a funeral conflict, and the NP, SSD, and DON confirmed there was no notification to the provider or referral to in-facility psychiatric services despite available behavioral health support.
A resident with depression, cognitive decline, and severe cognitive impairment had an ordered psychology/psychiatry consult that was not completed for months despite ongoing agitation, refusal of care, yelling at staff, and other disruptive behaviors. The DON acknowledged the consult should have been arranged and completed, but the facility’s psych provider was on maternity leave and the covering provider did not appear, so no service was provided.
A resident made suicidal statements and later threatened to commit suicide, but the clinical record lacked evidence of a self-harm/suicide assessment or provider notification. The care plan was also not updated to include triggers, goals, or interventions for suicidal ideation, and facility leaders confirmed the gaps in the record.
Failure to identify resident-specific behavioral triggers: A resident with anxiety, depression, irritability, and trauma history was observed tearful and distressed while discussing multiple family losses and conflict with other residents and staff. Records showed psych notes about holiday-related distress, ruminating, accusations of poisoning, and mild paranoia, but the care plan did not include key triggers such as holidays/Thanksgiving, lab draws, grief, or paranoia, and did not list relaxation as an intervention.
Failure to address depression and psychosocial needs: A resident with dementia, depressive disorder, and behavioral issues had PHQ-9 scores showing mild to moderate depression, but the record did not document follow-up for the increased score or consistent implementation of behavioral health recommendations. The resident often isolated in his room, declined activities, and had care plan interventions for depression and verbal aggression that were not consistently reflected in the chart or carried out as documented.
A resident with depression, anxiety, and insomnia had documented worsening depressive symptoms, including low mood, poor sleep, fatigue, poor appetite, and loss of interest. Although the care plan included psych services and the resident reported feeling very depressed and wanting therapy, there was no documented timely psych follow-up after staff emails and notes requesting reassessment. The resident stated the psychologist came only once and took over 10 weeks to return, while the psych NP later noted the resident was highly anxious and very depressed and that follow-up had been delayed for about 3 months.
Failure to Address Behavioral and Psychosocial Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services to address known psychosocial concerns for one resident who had verbal outbursts, cursed, and used derogatory language toward staff. The resident was cognitively intact with a BIMS score of 15 and had diagnoses including end stage renal disease and a traumatic amputation of two or more right lesser toes. The Quarterly MDS identified verbal behavioral symptoms directed toward others, but the resident was not referred for in-facility psychiatric services or grief counseling despite the facility’s available behavioral health services. Record review and interviews showed that the resident missed dialysis treatments because of behavior and because one make-up dialysis appointment conflicted with his son’s funeral. The resident representative stated she was concerned about the missed medical and dialysis appointments and was not aware of any grief counseling offered after the death of the resident’s son. The DON confirmed that the resident missed dialysis because of behavior and that the resident also missed a dialysis appointment on the day of the funeral. She stated that the resident had shown a change in behavior during his stay and that staff received the brunt of his behavior. The NP stated she was not notified that the resident missed dialysis treatments and that there was no documentation that the covering NP was notified. The SSD confirmed awareness of the resident’s verbal outbursts but had not notified the primary healthcare provider and had not referred the resident to behavioral health services. The DON also confirmed that no referral was made to behavioral health contract services and that the resident’s doctor or NP was not notified that his behavior interfered with his scheduled dialysis treatments.
Delayed Psychology/Psychiatry Consult for Resident With Behavioral Symptoms
Penalty
Summary
The facility failed to ensure timely completion of a physician-ordered psychology/psychiatry consult for one resident with depression, age-related cognitive decline, and cognitive communication deficit. The resident’s MDS dated 2/25/26 indicated severe cognitive impairment and problematic behaviors directed toward others, including threatening, yelling at, or cursing at staff. An order dated 7/30/25 for a psychology/psychiatry consult with follow-up treatment as indicated was present in the order summary, but there was no evidence the consult was completed during the 11-month period reviewed. Facility progress notes documented ongoing behavioral and psychological concerns during that period, including increased evening agitation, multiple outbursts toward staff, fear of staff leaving the room, refusal of care, yelling and waving her hand aggressively at staff, calling police to complain that she was being held captive, and another episode of yelling during care. During interview, the resident stated one incident reported as abuse occurred because a CNA was rushing her. The DON stated the consult should have been arranged and completed and explained that the facility’s psychology/psychiatry provider had been on maternity leave and the covering provider failed to show up, resulting in no service being provided.
Failure to Assess and Care Plan Suicidal Ideation
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed suicidal ideation and signs of self-harm. The resident’s care plan meeting note dated 4/30/26 documented that the resident said he/she might as well commit suicide, but the clinical record lacked evidence that the resident was assessed for self-harm or suicide ideation, and there was no evidence that the provider was notified of the statement. A later provider communication note dated 5/10/26 documented increasing confusion and a threat to commit suicide that night. The resident’s most recent care plan update on 5/12/26 did not include goals or interventions related to suicidal ideation. During interviews on 6/2/26 and 6/3/26, the Market Clinical Lead, Social Service Director, Market Clinical Advisor, DON, and Market Clinical Lead confirmed there was no evidence the doctor had been notified, no evidence the resident had been assessed for self-harm/suicidal ideation, and no evidence the care plan had been updated to include triggers, goals, or interventions for threat of self-harm or suicide ideation.
Failure to Identify Resident-Specific Behavioral Triggers
Penalty
Summary
The facility failed to ensure behavioral triggers were identified and assessed for a resident with diagnoses including left side weakness due to a stroke, anxiety disorder, insomnia, irritability and anger, major depressive disorder, and unspecified affective mood disorder. The resident’s annual BIMS score was 15, indicating no cognitive loss. During observation and interview, the resident was tearful while discussing the deaths of their mother and brother, stated they felt alone, described multiple family losses and the deaths of three friends at the facility, and reported conflict with two other residents who antagonized them and accused them of receiving preferential treatment. The resident also reported distrust of staff, alleged that the Dietary Manager shared protected health information with other residents, stated the facility arranged an outside agency evaluation without permission, and alleged a staff member intentionally struck them with another resident’s wheelchair. Record review showed psychiatric notes documenting concern about holidays and the upcoming anniversary of the brother’s death, ruminating on past events, accusations that staff attempted to poison the resident, and mild paranoia related to state examinations and dietary restrictions. The care plan identified trauma related to the deaths of the resident’s father, mother, and brother, and identified triggers such as other residents being assisted before them and the presence of a specific resident, but it did not include holidays, especially Thanksgiving, lab draws, paranoia, grief, or relaxation as an intervention. The Social Service Director stated the resident was paranoid at times and was aware the resident had been verbally abusive to a lab technician, but was not aware the resident blamed the hospital lab for their mother’s death.
Failure to Address Depression and Psychosocial Needs
Penalty
Summary
The facility failed to ensure a resident with diagnoses including dementia with behavioral disturbance and depressive disorder received appropriate treatment and services to support mental and psychosocial well-being. The resident’s MDS showed moderate cognitive impairment, verbal behaviors toward others, and depression identified through PHQ-9 screening. The resident also received an antidepressant and an antipsychotic medication, and the record showed no gradual dose reduction attempt or documentation that it was clinically contraindicated. Record review and observations showed the resident spent much of the day in his room with the lights off and blinds closed, often sat alone in the dining room, and told staff he did not like to participate in facility activities. The care plan identified depression, self-isolation, verbal aggression, and the need for psychosocial monitoring, emotional support, activities of interest, and behavioral interventions such as calm approach, positive reassurance, one-on-one interactions, and a quiet environment. A psychiatry note also recommended a more proactive approach to encouraging the resident to attend activities, such as telling him it was time to go rather than asking if he wanted to go, but this recommendation was not reflected in the electronic record. The resident’s PHQ-9 scores showed mild depression in September 2025, then moderate depression in December 2025 and again in March 2026, but the record did not show documentation addressing the increased score, follow-up, interventions, or services offered. Physician orders included monitoring for behaviors, isolation, side effects of psychotropic medications, and offering non-pharmacological interventions, but the record showed these interventions were not consistently implemented or documented as effective. Staff interviews confirmed the resident could become upset when approached in a way that suggested he was blamed for resident-to-resident altercations, and the administrator and social services director acknowledged they could not locate documentation showing why the PHQ-9 score increased or that the behavioral health recommendation had been incorporated into the care plan.
Delayed Psych Follow-Up for Resident With Depression and Anxiety
Penalty
Summary
The facility failed to ensure a resident with diagnoses of depression, anxiety, and insomnia received appropriate treatment and services to address worsening psychosocial symptoms and attain the highest practicable mental and psychological well-being. The resident’s assessment documented frequent depressive symptoms, including little interest in activities, feeling down nearly every day, sleep disturbance, fatigue, poor appetite, and feelings of worthlessness, while also receiving antianxiety and antidepressant medications. The care plan identified depression and anxiety and included monitoring for suicidal ideation and family involvement, and physician orders included psychiatry and psychology consultation and multiple psychotropic medications. Record review showed the resident reported increased depression and ongoing anxiety during the psychiatric nurse practitioner’s initial evaluation, with a plan to follow up in 6 weeks. A social worker later documented depressive symptoms and emailed psychiatric staff to request assessment after the resident scored a 12 on the PHQ-9, but there was no documented evidence the resident was seen by the psychiatric RN. An interdisciplinary note later documented the resident was requesting psych follow-up, and another progress note stated the resident wanted to be added to the psych list, yet there was no documented evidence of a timely psych follow-up until the psychiatric nurse practitioner saw the resident about 12 weeks after the initial evaluation. During observation, the resident was lying in bed dressed, quiet, and staring off with an unfocused, blank expression, and stated they were depressed and nothing was being done. The resident reported they had previously seen a therapist weekly before admission, that the psychologist had only come once and was supposed to see them weekly but took over 10 weeks, and that they had told the facility at the beginning of the year and again a month later that they were going through a great depression. Staff interviews reflected that some staff were aware the resident seemed down or more anxious, while others stated they had not noticed major mood changes. The psychiatric nurse practitioner stated the resident was highly anxious and very depressed and that the facility had not asked for the resident to be seen again, resulting in a follow-up gap of about 3 months.
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