**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to reassess and monitor one of three sampled residents (Resident 1) for signs and symptoms of depression with mood changes after Resident 1's family member expressed her father's feelings of wanting to die. This failure led to the decline of Resident 1's mental health and psychosocial (emotional) wellbeing which resulted in Resident 1's death by suicide on October 27, 2023. Findings: A review of Resident 1's clinical record, the Face Sheet contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which included: Parkinson's (brain disorder that causes unintended or uncontrollable movement) and encephalopathy (disturbance in the way the brain functions.) A review of Resident 1's clinical record, the Licensed Nurses Progress Note dated September 18, 2023, indicated, Late entry: Today Care conference was conducted .family member stated her dad was feeling sad and wanted to go home with her. Family member explained that she was unable to provide care for him at home. Order for psychiatric (mental illness) consult was input and sent to [Psychiatrist (specializing in the diagnosis and treatment of mental illness) name]. The Charge nurse (caring for Resident 1) was informed to follow up and to continue to monitor resident. No documentation could be found to show Resident 1 was monitored daily for sadness or mood changes after this note. A review of Resident 1's clinical record, the Physicians Order dated September 18, 2023, indicated May have consult with psychiatrist due to verbalization of feeling sad. A review of Resident 1's, Minimum Data Set (MDS- set of assessments), Section D for Mood, dated September 18, 2023, indicated over the last two weeks Resident 1 had the presence of these symptoms: little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, poor appetite, or overeating. The frequency of these symptoms averaged between 7 to 14 days. Section D indicated the symptoms happened half or more of these days. Resident 1's Total Severity Score (an indicator of depression) was 11. A score of 11 indicated Resident 1 had signs and symptoms of moderate depression. No documentation could be provided of resident 1's medical records that indicated Resident 1 was monitored or assessed daily for sadness, mood changes or signs and symptoms of depression after this assessment. A review of Resident 1's Care Plan (outline of what needs to be done to manage the care, needs of a resident) titled Mood dated September 18, 2023, indicated Resident 1 was at risk for decreased psychosocial well-being and adjustments issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social or spiritual wellbeing related to: a. feeling down, depressed, or hopeless, b. Feeling tired or having little energy, little interest, or pleasure in doing things, c. poor appetite or overeating, d. trouble falling, staying asleep or sleeping too much. The interventions listed included: Assess for clinical issues that may be causing or contributing to the mood pattern. No documentation could be found to indicate Resident 1 was monitored or assessed daily for sadness, mood changes or signs and symptoms of depression after this care plan was initiated. A review of Resident 1's clinical record, Interdisciplinary Team Conference Summary Note (IDT- team members from different disciplines working together to make decisions), effective date September 18, 2023, at 9:37 AM and signed by a Licensed Vocational Nurse on October 27, 2023, indicated New orders for patient to be seen by psychiatrist regarding the resident stating that he is feeling sad. Sent over face sheets and order to (Psychiatrist) for patient to be seen from verbalization from the family member that her father stated he was sad and wanted to go home. Informed [Psychiatrist name] about order so patient can be seen, continuing to monitor. No documentation could be found that indicated Resident 1 was monitored or assessed daily for sadness, mood changes or signs and symptoms of depression after this note. A review of Resident 1's, Physicians Order dated September 27, 2023, indicated Last cover date (end of insurance coverage) was September 29, 2023. Resident 1 became a custodial care resident (receives non-medical care that can be safely given my non-licensed caregivers at home or in a nursing home) of the facility on September 30, 2023. A review of Resident 1's, Physician's Progress Note dated September 25, 2023, indicated Psychiatrist was unable to see Resident 1 because Resident 1 had (name of insurance carrier) and there was no prior authorization to see the Psychiatrist. A further review of the document indicated to refer Resident 1 to the neurologist (specialist in the diagnosis and treatment of disorders of the nervous system). A review of Resident 1's, Neuropsychological (the study of behavior, the mind, and their relationship with the central nervous system) Consultation Summary from [Name of Neurologist] dated October 16, 2023, indicated Parkinson's ., agitated before his evening medications. Resident had an altercation where he was physical with his family member (while in the facility) . No documentation could be found that indicated the facility documented the report of an altercation between Resident 1 and the family member before the neurological consult or after the consultation was completed. A review of Resident 1's clinical record, the Licensed Nurses Progress Note ' dated October 13, 2023, at 1:16 PM, indicated (Resident 1) left out on pass with family member in a wheelchair. The subsequent nurses note was dated October 15, 2023. No documentation could be found that indicated Residents 1's mood or behavior after his return to the facility on October 13, 2023. A review of Resident 1's Licensed Nurses' Progress Notes dated October 16, 2023, indicated the nurses note was a late entry which was documented on October 27, 2023, at 5:58 PM, the nurses progress note indicated, Received an order for Seroquel (antipsychotic medication used to treat agitation or depression), for agitation from [Neurologist name] during telehealth appointment. Family member was present during telehealth appointment. Consent obtained from family member. Order carried out. No documentation could be provided of incidents or behaviors that indicated Resident 1 was agitated. No documentation could be found in Resident 1's medical records, the nurses' notes, assessments, and the weekly summaries from September 18, 2023, to October 27, 2023, that demonstrated incidents of agitated behaviors that warranted the use of Seroquel. A review of Resident 1's Licensed Nurses' Progress Note dated October 30, 2023, at 11:25 PM, indicated upon cleaning the resident's room, around 11:15 PM, a handwritten note was found on the side table by a Registered Nurse and Unit manager. The Family member was called and made aware of the note. The nurse read the note to the family member. A review of Resident 1's medical records, the nurses' notes, nurses' assessment notes, and the weekly summaries dated September 18, 2023, to October 27, 2023, indicated Resident 1 was not monitored or assessed daily or weekly for signs and symptoms of depression, sadness, or mood changes. A review of Resident 1's History and Physical (H&P) dated September 19, 2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. During an interview with Licensed Vocational Nurse (LVN 1) on October 30, 2023, at 3:11 PM, LVN 1 stated, On October 27, 2023, I walked into the room to give medication. I called out his name. Resident 1 did not respond. Resident 1 had the blanket over his head. He was on his back looking up and the ceiling. No response. I looked to see if he was breathing. I pulled the blanket back. The patient belongings bag was tied around his neck. The black charger cord was wrapped around his neck three or four times. LVN 1 stated further, Seroquel? We received an order for 25 mg (milligram, unit of measurement) of Seroquel for agitation. Resident 1 was not agitated for me. I got the order for Seroquel from [Neurologist's name]. The family member set the appointment to see the Neurologist. No documentation could be provided that indicated Resident 1 had episodes of agitation or changes in mood. During a phone interview with Resident 1's family member on October 30, 2023, at 3:26 PM, the family member stated (Resident 1) was not happy and wanted to go home. The last week that he was in the facility he was making the adjustment. Doing the activities and making friends. (Resident 1) was saying that he wanted to die at home. (Resident 1) did say it again, that he wanted to die, when he was in the facility, the first week he was there. I asked them for a psychiatric evaluation. That request for a psychiatric evaluation was a month ago. I told the nurse one time. She was in the room with me when (Resident 1) said that he wanted to die and that's when I asked for a psychiatrist to see him. One of them I told was (Registered Nurse 1, RN 1). (RN 1) said, they would put it in the notes that they would have someone go talk to him. A continuation of the phone interview with Resident 1's family member on October 30, 2023, at 3:26 PM, family member stated further, I had gone to see him after my daughter's wedding. He was upset because he did not go to the wedding. On October 13, 2023, I took him out on pass, and he had no intentions of going back there. He wanted to go home. He was trying to walk away, and I grabbed his shirt, and he started punching at me. It was not like him at all. I said you're hurting me. I yelled for help. (Staff members) eventually came out and helped me . (Staff members) told me to drive away because he was trying to resist going inside. He said he wanted to die the next day. Resident 1's family member then stated, on (October 16, 2023), the neurologist wanted to make sure his medications were right with LVN 1, who was there at the time of this visit. I told the Neurologist about the incident on Friday and the neurologist was concerned that it was the first sign of dementia. That's why the Neurologist ordered the Seroquel. During a phone Interview with LVN 2 on October 30, 2023, at 4:35 PM, LVN 2 stated, the day, October 13, 2023, Resident 1 went out on pass with his family member, Resident 1 took a shower early and was excited. When Resident 1 came back from pass, he said he did not want to go back to the facility. Resident 1's family member asked if we could redirect him LVN 2 stated they redirected him with pizza, but Resident 1 did say he wanted to go home with the family member. No documentation could be found that indicated Resident 1 was assessed or monitored for behavior or mood after he returned from his out on pass visit with his family member. During a phone interview with LVN 3 on October 30, 2023, at 4:53 PM, LVN 3 stated on October 13, 2013, I noticed he was with his family member. I noticed that he was mad at the family member. He was hitting the family member when he came back from out on pass. When LVN 3 was asked further about Resident 1 hitting the family member, LVN 3 stated, I don't remember who told me about (Resident 1) hitting the family member I didn't pay much attention. No documentation could be found that indicated Resident 1 was assessed and or monitored for changes in mood, signs and symptoms of depression or sadness when he returned from out on pass on October 13, 2023. During an interview with the Director of Nursing (DON) on October 30, 2023, at 6:01 PM, the DON stated Registered Nurse (RN 1) reported Resident 1 was mad at the family member, because the family member can't take him home. (RN 1) said, I can't, I don't want to be caught in the middle. (RN 1) said the family member looked like help me that day (October 13, 2023.) (Staff members) lured him back inside with pizza and that was it. I didn't know or they did not mention anything about Resident 1 hitting the family member. There was no documentation about that. (RN 1) should have documented that. The DON stated and confirmed the facility has two psychiatrists [NAMES] and they did not see Resident 1 due to insurance. The DON further stated if Resident 1's psychiatrist consultation was not covered by his insurance. Case management was to follow up. During a concurrent interview and record review of Resident 1's medical record with the DON on October 30, 2023, at 6:01 PM, DON stated, Resident 1's Care Plan, (outline of what needs to be done to manage the care needs of a resident) for Mood, dated September 18, 2023, was reviewed. The DON stated, We don't monitor at risk care plans for mood. After speaking with the social services director (SSD) and reviewing the clinical records for Resident 1, the DON then stated, They should have documented about his mood. The DON could not provide documentation that indicated Resident 1 was monitored daily or weekly for sadness, signs and symptoms of depression or mood changes. The DON confirmed there was no documentation to show Resident 1 was monitored and assessed for changes to mood, signs and symptoms of depression or sadness daily or weekly. During an interview and record review on October 31, 2023, at 2:20 PM with the Assistant Director of Nursing (ADON), ADON stated, The first assessment on Minimum Data Set (MDS) dated [DATE], Section D (Mood), based on the PHQ9 (patient health questionnaire, is an instrument used for screening, diagnosing, monitoring, and measuring the severity of depression), the total severity score was 11. All this was based on Resident 1's interview. The ADON, stated the MDS was done for every admission, or significant change in condition. I don't think a new Preadmission Screening and Resident Review (PASRR) was done, because we would only have to do it again if the resident had a Change of condition. The one we have is from [outside hospital]. There was no suicide assessment done because he was negative on his PASRR from the [outside hospital]. The ADON stated, there was no care plan developed for Seroquel. The ADON further stated, for Seroquel medication, monitoring was not documented on Resident 1's Medication Administration Record (MAR). It's not on the MAR. The ADON verified and confirmed that Resident 1's feeling of sadness and monitoring was not documented in the clinical records and the facility was unable to provide any documented evidence. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status dated February 2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's attending physician when there has been a: accident or incident involving the resident .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly, i. specific instructions to notify the physician of changes in the resident's condition. During a review of the facility's policy and procedure titled, Safety and Supervision of Residents dated July 2017, the P&P indicated Our facility strives to make the environment as free from accident, hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Individualized, Resident-Centered Approach to Safety .4. Implementing interventions to reduce accident risks and hazards shall include the following: d. enduring that interventions are implemented; and documenting interventions. During a review of the facility's P&P titled, Depression dated November 2018, the P&P indicated, .3. The staff will screen residents for depression, using appropriate screening tools, on admission and subsequently, if suggested by changes in mood, function, or behavior. 4. Staff will evaluate residents for possible evidence of mood disorder. A. signs and symptoms may include depressed mood most of the day, almost every day diminished interest or pleasure in most activities, B. Examples of risk factors for depression include a medical diagnosis associated with a high risk of depression, new admission or change in environment, loss of autonomy, privacy, function . The physician will evaluate underlying causes of mood disorder, including depression and contributing factors . The facility to reassess and monitor one of three sampled residents (Resident 1) for signs and symptoms of depression with mood changes after Resident 1's family member expressed her father's feelings of wanting to die. This failure led to the decline of Resident 1's mental health and psychosocial (emotional) wellbeing which resulted in Resident 1's death by suicide on October 27, 2023. On November 01, 2023, at 9:57AM, after interviews and record reviews, an immediate jeopardy (IJ-Immediate Jeopardy means a situation in which immediate corrective action is necessary due to provider's noncompliance with requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to an individual receiving care in a facility) was called under F684 in the presence of the Director of Nursing, Assistant Director of Nursing, and facility Consultant. A corrective action plan was requested on November 01, 2023, at 9:57 AM. A corrective action plan was provided and accepted by facility on November 02, 2023, at 3:41 PM included: Social Services provided psychosocial support to both roommates as needed noted on October 28,2023, October 29, 2023, October 31, 2023, and November 01,2023; Social services department to notify psychologist to provide psychosocial support to affected staff. Facility to conduct assessments using PHQ2-9 (an instrument used for screening, diagnosing, monitoring, and measuring the severity of depression) assessment to residents with diagnosis of Parkinson's Disease. Depression and are alert, oriented x 4 to check for signs and symptoms of depression. Any residents identified on assessment conducted with a score of 1 or above will have behavior monitoring in place, care plan and behavioral management with Psychiatrist. If they trigger Section D if 10 or above, they are monitoring and referred on psych eval, social services will notify the Minimum Data Set nurse (MDS). Systemic changes the facility will identify and monitor residents with depression, or a decline in mood to prevent serious injury, serious harm, serious impairment death. In-service November 02, 2023, on Systemic changes with facility psychiatrist on Suicide Prevention recognizing signs and symptoms of depression, changes or decline in mood and or suicidal ideation. A trigger on MDS section D with no anti-depression medications, they are still assessing and documenting what the actual behavior, in Medication Administration Record (MAR) for monitoring. The DON and ADON conducted an all-staff in-service on November 01, 2023, focusing on recognizing, monitoring, and addressing Suicidal ideation and/or warning signs of Depression. DON conducted in-services on October 28, 2023, and October 30, 2023, to staff including recognizing, monitoring, and addressing Suicidal ideation and/or warning signs of Depression. ADON conducted in services to staff on October 29, 2023, to staff including recognizing monitoring and addressing suicidal ideation and/or warning signs of Depression. The facility Social Services Staff will conduct Social Services Assessment of residents upon admission, quarterly, annually, and for significant change in status assessment. They are going off the MDS calendar, for initial assessment, it monitors behavior. MDS nurse and Social Services working on this together. Quality Assurance Nurse (QA)/Assistant Director of Nursing ADON conducted a facility wide audit on November 01, 2023, of all residents with psychological diagnoses and or receiving psychotropic (medications that affect mental function, behavior, and experience) medications, and residents with a PHQ2-9 total severity score of 1 or higher, ensured care plans and behavior monitoring are in place. Facility Social Services staff conducted interview for residents at risk for depression, decline in mood, and potential psycho-social conditions October 28, 2023, October 29, 2023, and October 30, 2023. Observation of the all-facility staff will be in-service today November 02, 2023, by Psychiatrist doctor regarding identifying/recognizing warning signs and suicidal ideation/symptoms of depression, decline in mood, and change in psycho-social condition, and the facility process to provide necessary psychosocial care to the resident. Observation of all facility staff in-service today, November 02, 2023, by the Director of Nursing regarding the systemic changes that the facility made to prevent this event from re-occurring. Upon PHQ2-9 assessment following MDS calendar, if the resident has a total severity score of 1 or higher, the facility will initiate care plan addressing risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing and also add an order to monitor signs and symptoms for depression every shift & notify Medical Doctor accordingly. This will be initiated November 01, 2023, and process maintained by facility. Based on the mood interview score, if score 1 or higher they will implement on every shift, behavior monitoring and document based on the questions triggered, social service with refer to psychiatric evaluation for assessment. The Quality Assurance Nurse and ADON will review the residents with orders of psychotropic medications using PCC (electronic medical record system) Dashboard to ensure the orders are with correct indication, behavior monitoring & care plan and will continue review new orders daily. Documents reviewed. Observation of Director of Nursing and Assistant Director of Nursing will conduct follow up in-services to all staff on November 02, 2023, to ensure they are aware of immediate plan of action, and new systemic changes to prevent serious injury, serious harm, serious impairment, or death of a resident in the future. The facility plans to monitor and provide assistance to residents identified with depression, or a decline in mood to prevent serious injury, serious harm, serious impairment death. MDS and social services are working side by side and the QA and the psychiatrist doctor with physician assistant. Facility in process in asking for another doctor to come in and assist facility. In the event the facility identifies a resident with depression, decline in mood, or a change in psycho-social status, the facility will provide assistance by initiating the following: 1. change of condition, notifying primary care physician, initiating 1 on1 supervision or until the resident is stable or evaluated in the Acute Care Setting, referral for psychology (study of the mind and behavior) or psychiatry (treatment of mental illness) services, implementation of interventions for monitoring the residents' depression, decline in mood, or change in psycho-social condition including but not limited to social contact rounds by Social Services staff, Activities staff, Facility chaplain or Spiritual counselor. 2. In-service for staff regarding implementation of plan of care, medication administration, monitoring for manifestations of identified behavior, and monitoring for side effects related to psychotropic medications. 3. Behavior management meetings monthly with QA Nurse, Social Services Staff, IDT, and Psychiatrist with Gradual Dose Reduction (GDR) if indicated/ordered. If not appropriate for GDR, Behavioral IDT will document contraindication in resident's record. 4.The Facility will aid residents with consultation orders for Psychiatry or Psychology that do not have insurance coverage for services that are required. 5. Residents with contracted insurance benefits that are not covered for Psychiatry or Psychology services in the facility will be provided will still be seen at the incurred cost to the facility as indicated/ordered and evaluated by the contracted Psychiatrist/Psychologist. As of November 02, 2023, the facility's psychiatrist will be seeing residents even if no insurance. And the Interdisciplinary team (IDT), social services will continue with documentation on progress notes. 6. QA Nurse will audit weekly for new residents with ordered Psychiatry/Psychology consults. Any findings will be reported to Social Services, Director of Nursing, Assistant Director of Nursing (immediately within 72 hours). 7. SSD will report monthly any resident with reported signs and symptoms of depression as based on the PHq2 MDS triggers via log to report the interventions provided and outcome during the QA Meeting to monitor for trend. Effective November 01, 2023, new form used, the PHQ9-2 log, used if is there is a 1-9 trigger. The resident is on the list for monitoring and actions exhibited behaviors and psych-eval order obtain from primary doctor and referred to psychiatrist. The immediate jeopardy was removed after the Corrective action plan was verified to be implemented through observations, interviews, and record reviews on November 02, 2023, at 3:48 PM in the presence of the Director of Nursing and Social Services.