Complaint·May 22, 2023

Staff contacted R1 over the phone on 3/13/2022, in which R1 was making suicidal ideations. In response, staff contacted the local police department and informed them of the incident. R1 ultimately returned to the facility on 3/14/2022. Staff met with R1, and although R1 appeared to be in a better mood, staff contacted the county suicide prevention hotline on 3/15/2022 for additional feedback. Staff encouraged R1 to contact emergency services if they continued to experience suicidal ideations. On 3/16/2022, R1 began to experience suicidal ideations, in which staff responded by contacting the local police department. Staff contacted emergency services, and R1 was ultimately transferred to a psychiatric unit and did not return to the facility. Interviews and records review revealed that upon admission to the facility on 1/25/2018, R1 had a diagnosis of anxiety and depression. As a result, R1 had regularly consulted with a psychiatrist with regards to managing their diagnosis. Records documented that R1 was an ‘independent and active’ resident, owned their own vehicle, and participated in their own ‘self-directed activities’. A review of internal care notes confirmed that staff were aware of R1’s diagnosis and had regularly checked in with R1 regarding their increased depression and anxiety. Reviewed notes documented that R1 had recently seen the facility social worker, who documented that R1 continued to struggle with symptoms of depression and highlighted that R1 received psychiatric services from the local clinic. Notes also indicated that R1 had seen their psychiatrist on 3/4/2022 at 3/8/2022, who assessed R1 and adjusted R1’s medications accordingly. Given the events that took place on 3/13/2022, the LPA observed a care note created on 3/15/2022 at 2:22 p.m. indicated that R1 was scheduled to speak to their psychiatrist on 3/16/2022 at 11:00 a.m. “if [R1] is willing to speak to [them]”. Per the note, it appears that staff had informed R1’s physician about the change of condition and scheduled an appointment, despite the claim that R1 may not speak to them at the time. The date and timing of the note was entered prior to the submission of this complaint to our department. Based on the information obtained in interviews and records review, there is insufficient evidence to support the claim that staff failed to inform R1’s physician of R1’s change of condition. Per the investigation, staff contacted both R1’s physician and psychiatrist about R1’s change of condition. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued to the Administrator.