Health inspection·March 24, 2023

F740 Behavioral Health Services CFR(s): 483.40 §483.40 Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. This REQUIREMENT is not met as evidenced by: On 9/27/22 at 1:00 pm, an unannounced visit was conducted at the facility to investigate facility reported incident of patient’s attempted suicide. The facility failed to address suicidal ideation (thinking about wanting to end one's own life) when the facility did not re-assess Resident 2's verbalization "I no longer wish to be here " on 9/8/22, and the facility did not create and implement a care plan for suicidal ideation. This resulted in Resident 2's suicide attempt on 9/21/22, by using scissors to cut his neck. Findings: 1. During review of Resident 2's clinical record, Resident 2 was admitted on 5/12/22 with diagnoses including generalized anxiety (persistent worry and fear) disorder, depression (elevation or lowering of a person's mood), and paraplegia (paralysis of the lower body), and previous suicide attempt. Review of Resident 2's minimum data set (MDS, resident assessment tool) dated 8/26/22, indicated Resident 2 was cognitively intact and required extensive assistance to perform activities of daily living (ADLs, things like bathing, eating, and toileting). Resident 2 had mood symptoms present of feeling down or depressed and was moving more slowly or was increasingly fidgety. Review of Resident 2' pre-admission screening and resident review (PASRR, is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) dated 5/13/22, indicated positive for Level 1 screening which prompted a PASSR Level II (A Level II is necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate) evaluation. However, PASSR II evaluation was not completed. During an interview with Administrator (ADM)and Director of Nursing (DON) on 9/30/22 at 1:30 PM, both stated PASRR II evaluation was never completed for Resident 2. Review of Resident 2's physician order dated 9/2022, indicated "Escitalopram oxalate 5 milligram (mg, measurement unit of mass) 1 tablet a day for depression; Diazepam 5 mg. Give 1 tablet by mouth every 8 hours as needed for anxiety/restlessness “. During review of the physician's note dated 9/8/22 indicated that Resident 2 stated "I no longer wish to be here " and agreed to speak to the psychiatry team. During an interview with the DON on 10/28/22 at 10:40 AM, DON stated that no documentation was present in Resident 2's clinical record between care providers (doctors, NP, nurses, staff, etc.) regarding the assessment or lack of assessment of suicidal ideation in Resident 2. DON also stated that the referral on 9/8/22 from the doctor to Psych NP was the only referral/ communication between staff regarding Resident 2's suicidal ideation. Review of the psychiatry nurse practitioner's (NP) note dated 9/9/22 indicated that Resident 2 has had suicidal thoughts, but the NP was unable to evaluate the resident... Will visit again next time I am in the building. Plan: no changes currently “. During an interview with the ADM on 10/20/22 at 11:55 AM, ADM stated that Resident 2 had verbalized to the physician on 9/08/22 that he did not wish to be here. The ADM viewed the sentence was in the context of the heatwave at the time, as Resident 2 was sitting in front of the fan. The ADM stated that if they knew Resident 2 had any suicidal ideation then they would have searched Resident 2 for hazardous objects, provided safe cutlery, and performed safety checks on Resident 2 every 15 minutes. During an interview with the Director of Nursing (DON) on 10/28/22 at 10:40 AM, the DON stated the NP did not come back to the facility to re-evaluate Resident 2. DON acknowledged the NP should have re-evaluated Resident 2 to assess his suicidal thoughts. Review of Resident 2's care plan titled "at risk for psychosocial well-being due to adjustment to skilled nursing facility " created and initiated on 5/21/22, indicates "the facility will refer to mental health team as needed and contact social services for follow up if exhibiting behaviors of depression, anxiety, anger, delusions, or adjustment concerns “. Interview with the Social Worker (SW) and Case Manager (CM) on 9/30/22 at 3:20 PM, the SW and CM stated no referral was made or visit/s made by the SW or CM to address suicide. Review of facility's policy and procedure titled, "Behavior Assessment, Intervention and Monitoring " revised March 2019, states that the "Facility will provide, and residents will receive behavioral-health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment “. The policy also stated the "Resident will have minimal complication associated with the management of altered or impaired behavior. " Per this policy, the facility will "thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors “. Under the section of "Monitoring “, the policy states that "If the resident is being treated for altered behavior or mood, the interdisciplinary team (team treating the Resident that consist of the Physician, Nurses, social worker, and administration) will seek and document any improvement or worsening in the individual's behavior, mood, and function " . 2. Review of Resident 2's clinical record, indicated there was no care plan to address his suicidal ideation. During an interview with the DON on 10/28/22 at 3:56 PM, she stated that there was no care plan for addressing Resident 2's suicidal ideation, because the facility staff did not re-assess Resident 2 when he stated he no longer wish to be here. During an interview on 10/04/22 at 11:34 AM with Licensed Vocational Nurse (LVN 2) for Resident 2 on the night of 9/21/22, LVN 2 stated that they did not do safety checks on Resident 2 at the time of the incident because she was unaware of Resident 2's suicide ideations. LVN 2 also stated that had she known about Resident 2's suicidal thoughts, LVN 2 would have done periodic safety check on him. During an interview with the Certified Nurse Assistant (CNA 1) on 10/10/22 at 2:33 PM, CNA 1 stated she did not do a safety check for Resident 2 prior to the incident because she too was unaware Resident 2 had suicidal ideations. During an interview with the social worker (SW) on 10/27/22 at 11:11 AM, SW stated that her department was never notified that Resident 2 had suicidal thoughts. The SW stated if the department was made aware, then they would have formulated a plan with the care team to keep Resident 2 safe. Review of Resident 2's progress notes dated 9/21/22 indicated "At 12:36 a.m., while charting at the nursing station, writer heard resident yell out, "I'm going to slit my neck". This writer immediately ran into resident's room and saw resident with small amount of blood flowing down his neck. Applied pressure to wound, initiated code blue (Emergency Code for immediate medical attention) and dialed 911 for suicide attempt. Asked resident what item he used; resident stated scissors. Asked resident where the scissors are, resident refused to give information ...Resident turned to his side table and pulled out green pair of scissors. Nurse standing on right side of resident able to confiscate scissors out of resident's hands safely. Resident refused to state where he obtained the scissors from. " Review of Resident 2's history of present illness (HPI) from acute hospital dated 9/21/22, indicated "At SNF (skilled nursing facility) where he resides, Resident 2 attempted suicide by using trauma shears to neck. He reports 2 other suicide attempts. He says he does not see life worth due to his paraplegia and chronic pain and wants a cocktail (mixture of medications) to die but says he cannot find a doctor to give him anything. He emphasizes he does not want to return to "that hell " (SNF) ...Resident 2 confirmed attempting suicide two other times in addition to the one he was admitted for, while at the skilled nursing facility. Resident 2 stated that he does not see life worth of living due to his paraplegia, and wants a "cocktail " to die, but can't find a doctor to help him. Resident 2 stated that he feels likes "he can no longer be mobile with his wheelchair " and his "activity has declined during his skilled nursing stay " . Resident 2 verified causing an open wound to the throat was an attempt to suicide, and "his intent to die is 100% and that he will try any means possible " . Review of the policy titled "suicide threats " revised December 2007 indicated "All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in residents' behavior immediately. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present “. The facility failed to address suicidal ideation (thinking about wanting to end one's own life) when the facility did not re-assess Resident 2's verbalization "I no longer wish to be here " on 9/8/22, and the facility did not create and implement a care plan for suicidal ideation. This resulted in Resident 2's suicide attempt on 9/21/22, by using scissors to cut his neck. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.