WATAUGA, TEXAS - Federal inspectors uncovered critical safety failures at North Pointe Nursing and Rehabilitation LP after a resident with documented suicidal ideation ingested hand sanitizer in an attempt to end her life, leading to an immediate jeopardy citation that threatened the facility's Medicare participation.
Critical Mental Health Assessment Failure
The most serious violation centered on the facility's failure to properly assess and plan for a resident with known mental health risks. The resident, admitted to the facility with multiple psychiatric diagnoses including schizoaffective disorder, major depressive disorder, and documented suicidal ideation, was not provided with appropriate safety interventions despite clear warning signs in her medical history.
Records showed the resident's referral documentation from her previous facility explicitly noted a suicide attempt just weeks before her transfer. A progress note dated July 23, 2024, stated: "Resident is having suicidal attempts, suicidal thoughts. Sent to [Hospital] for further treatment." Despite this clear documentation, North Pointe's leadership team failed to implement any suicide prevention protocols or safety measures.
The facility's baseline care plan, initiated on August 6, 2024, completely omitted any mention of the resident's suicidal ideation diagnosis. Instead, the care plan focused solely on "attention-seeking behaviors" and maintaining professional boundaries with staff. This critical oversight left the resident without essential mental health monitoring and removed potential hazards from her environment.
The August 15 Incident
On the morning of August 15, 2024, the resident approached nursing staff at approximately 8:30 AM holding a small pocket-sized bottle of hand sanitizer with liquid staining on her shirt. She told staff she had consumed the sanitizer because she wanted to kill herself, continuing to express suicidal thoughts while emergency services were contacted.
The resident had become upset earlier that morning after being questioned about alterations she made to her hospital discharge paperwork from the previous day. Staff reported she had scribbled out some diagnoses and written in others. When confronted about these changes, she became distressed and later returned with the sanitizer bottle, which still contained approximately one-quarter of its contents.
During the 15-minute wait for emergency medical services, the resident repeatedly stated she wanted to die, telling staff that "no one loved her" and she "didn't belong in heaven." Staff maintained one-on-one monitoring and offered milk to counteract the ingested sanitizer, which the resident refused.
Systemic Communication Breakdown
Investigation revealed multiple points where critical information about the resident's suicide risk was available but not acted upon. The MDS Nurse who created the resident's face sheet had copied all diagnoses from the previous facility, including suicidal ideation, but assumed other staff members were aware of this information without verifying communication had occurred.
The Director of Nursing (DON) stated during interviews that she had reviewed the admission paperwork alongside the Administrator and Assistant Director of Nursing (ADON) but claimed not to have seen the suicidal ideation diagnosis or the documented suicide attempt. "If she would have seen that, she probably would have recommended [the resident] to a psychiatric facility instead of admitting her to their facility," the DON told investigators.
The Administrator acknowledged seeing the suicidal ideation diagnosis on the face sheet before admission but dismissed its significance, assuming it was historical rather than current. This assumption was made without consulting the resident's guardian or previous facility about the recency or severity of the suicide risk.
Hazardous Materials Left Accessible
The presence of alcohol-based hand sanitizer in resident rooms represented another significant safety failure. Following the incident, facility leadership conducted an immediate audit and removed all pocket hand sanitizers from resident rooms and common areas. This reactive measure highlighted the facility's failure to proactively assess and eliminate environmental hazards for vulnerable residents.
Industry standards require nursing homes to conduct environmental risk assessments for residents with mental health conditions, particularly those with documented self-harm behaviors. Facilities must identify and remove potentially dangerous items including sharps, medications, cleaning supplies, and products containing alcohol. North Pointe's failure to conduct such an assessment before or immediately after the resident's admission created the opportunity for the suicide attempt.
Pattern of Missed Warning Signs
The resident's guardian revealed additional concerning history that the facility failed to obtain during the admission process. In late April or early May 2024, the resident had previously attempted self-harm by drinking mouthwash and swallowing a keychain, requiring emergency endoscopy for removal. The guardian admitted forgetting to share this information during the transfer due to being overwhelmed by the resident's complex behavioral issues.
Multiple staff members reported that the resident exhibited escalating attention-seeking behaviors in the days leading up to the incident. She would enter staff offices uninvited, request physical affection from staff, and repeatedly ask if people liked her. When boundaries were enforced, she would become upset and claim no one cared about her. These behaviors, combined with her psychiatric history, should have triggered additional mental health assessment and intervention.
The night before the incident, the resident had been sent to the hospital complaining of stomach pain that escalated to chest pain claims. She returned with no new medical orders, but the pattern of seeking emergency medical attention—previously resulting in discharge from her prior facility for excessive 911 calls—was not recognized as a potential warning sign for emotional crisis.
Additional Issues Identified
Inspectors documented several other violations during their investigation. The facility lacked adequate policies for reviewing and acting upon mental health diagnoses during the admission process. Staff training on recognizing and responding to mental health crises was insufficient, with many employees unable to identify appropriate interventions for residents expressing self-harm intentions before the mandatory re-training following the incident.
Documentation systems failed to ensure critical diagnoses were communicated across all departments. The facility's morning clinical meetings, intended to review new admissions and care needs, had not identified or discussed the resident's suicide risk despite multiple opportunities in the ten days between admission and the incident.
Care planning processes were inadequate, with baseline care plans failing to address all documented diagnoses. The facility's policy required baseline care plans within 48 hours of admission to "promote continuity of care and increase resident safety," yet this fundamental requirement was not met for psychiatric conditions requiring the highest level of monitoring.
The facility's quality assurance program had not identified these systematic failures in mental health care delivery, admission screening, or environmental safety assessments before the incident occurred.
Immediate Jeopardy Removal
Federal surveyors issued an Immediate Jeopardy citation on August 16, 2024, indicating the facility's failures posed immediate risk of serious harm or death to residents. The facility implemented an extensive corrective action plan including comprehensive staff retraining on abuse and neglect identification, baseline care planning for mental health conditions, and prohibited items in resident areas.
All current residents were reviewed for mental health diagnoses requiring special precautions. One additional resident with suicidal ideation was identified and appropriate interventions were implemented. New protocols were established requiring daily review of all admission diagnoses during morning clinical meetings, with specific attention to mental health conditions requiring safety interventions.
While the Immediate Jeopardy was lifted on August 17, 2024, after verification of corrective measures, the facility remained out of compliance pending completion of staff training for all employees across all shifts.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Pointe Nursing and Rehabilitation Lp from 2024-08-17 including all violations, facility responses, and corrective action plans.
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