MANSFIELD, TX - State health inspectors identified serious deficiencies in suicide prevention protocols at The Pavilion at Creekwood during a complaint investigation completed January 5, 2025, after a resident expressed suicidal ideation without receiving appropriate immediate safety interventions.
Breakdown in Mental Health Crisis Response
The investigation centered on a critical incident involving Resident #1, who voiced suicidal thoughts on January 1, 2025. According to the inspection report, the facility failed to implement immediate safety protocols that are standard practice in healthcare settings when a patient expresses intent to self-harm.
When Resident #1 communicated suicidal ideation, the facility did not initiate one-on-one supervision—a fundamental safety measure designed to ensure continuous monitoring of at-risk individuals. This type of direct observation serves as the primary defense against self-harm in institutional settings, allowing staff to intervene immediately if a resident attempts to act on suicidal thoughts.
The inspection revealed that staff members did not follow established emergency procedures for mental health crises. Standard protocols in nursing facilities require immediate implementation of safety measures when residents express thoughts of self-harm, including continuous supervision, removal of potentially dangerous items from the environment, and prompt notification of appropriate medical and administrative personnel.
Resident #1 was eventually assessed by psychiatry services on January 2, 2025—the day after expressing suicidal ideation. The psychiatric provider determined the resident was not an immediate threat to herself and that hospital transfer was not appropriate at that time. The Social Services Director completed a suicide ideation assessment on January 3, 2025, again concluding the resident was not a threat to herself.
Understanding the Medical Significance
The gap between a resident expressing suicidal thoughts and receiving appropriate safety interventions represents a critical vulnerability in patient care. In mental health and geriatric medicine, the period immediately following disclosure of suicidal ideation is considered high-risk. Research in suicide prevention demonstrates that the time between ideation and potential action can be remarkably brief, making immediate response essential.
Suicidal ideation in nursing home residents presents unique challenges and elevated risks. Older adults in long-term care facilities may experience depression, loss of independence, chronic pain, social isolation, and medical conditions that contribute to thoughts of self-harm. The nursing home environment should provide protective factors through monitoring, engagement, and prompt mental health intervention.
One-on-one supervision protocols exist specifically because they have been proven effective in preventing suicide attempts in healthcare settings. This intervention involves assigning a staff member to maintain visual contact with the at-risk individual continuously, typically within arm's reach. The supervising staff member observes for warning signs, ensures the environment remains safe, and can provide immediate intervention if the resident's condition deteriorates.
The delay in implementing safety measures created a window of vulnerability during which the resident remained at potential risk without the protective monitoring that healthcare standards require. Even if a resident ultimately does not attempt self-harm, the absence of immediate safety protocols represents a systemic failure in crisis response that could have resulted in tragedy.
Columbia Suicide Severity Rating Scale Protocol
The facility's corrective action plan introduced the Columbia Suicide Severity Rating Scale as a standardized assessment tool. This evidence-based screening instrument is widely used in healthcare settings to evaluate suicide risk systematically. The scale assesses the presence and severity of suicidal ideation, including the specificity of any plans, availability of means, and intent to act.
Implementation of a standardized assessment tool addresses part of the deficiency identified during the inspection. However, the inspection findings emphasized that assessment alone is insufficient—immediate safety interventions must occur simultaneously when a resident voices suicidal thoughts, not after completing paperwork or waiting for evaluations.
The rating scale helps clinical staff determine the appropriate level of intervention, ranging from outpatient mental health follow-up for lower-risk cases to immediate psychiatric hospitalization for individuals deemed at imminent risk. By quantifying risk factors and protective factors, the assessment provides objective data to guide treatment decisions.
Notification and Communication Failures
The inspection identified deficiencies in the facility's notification procedures when residents expressed suicidal ideation. Proper crisis response protocols require immediate communication with multiple parties: the attending physician, facility administration, mental health professionals, and the resident's family or responsible party (when appropriate).
These notification requirements serve several purposes. The attending physician needs to be informed immediately to issue orders for psychiatric evaluation, medication adjustments, or hospital transfer if indicated. Facility administrators must be aware of mental health crises to ensure adequate staffing for one-on-one supervision and to fulfill regulatory reporting obligations. Mental health professionals, whether in-house psychiatrists or contracted services, should be contacted emergently to provide crisis assessment and intervention.
The failure to implement these notification procedures meant that critical decision-makers lacked real-time information about a resident's mental health emergency. This communication breakdown delayed appropriate interventions and prevented the facility's leadership from ensuring proper safety measures were in place.
Staff Training and Knowledge Gaps
Following the inspection, the facility conducted mandatory re-education for all licensed nurses and the Social Services Director on suicide precaution management. The training, completed by January 4, 2025, covered immediate implementation of one-on-one supervision when residents voice suicidal ideation, notification procedures for the Social Services Director, criteria for hospital transfer when a safe environment cannot be maintained within the facility, and completion of standardized suicide risk assessments.
Sixty-three staff members, including 16 Licensed Vocational Nurses, 24 Certified Nurse Assistants, 8 Registered Nurses, and various other personnel, completed the training by January 5, 2025. During follow-up interviews conducted between 1:10 PM and 4:57 PM on January 5, surveyed staff members were able to verbalize the updated protocols accurately, including who to notify and what interventions to implement when residents express suicidal thoughts.
The need for this comprehensive re-education suggests that existing training had been inadequate to prepare staff for mental health emergencies. Nursing facilities are required to provide ongoing education that equips staff to recognize and respond to psychiatric crises, yet the inspection findings demonstrated staff were not implementing fundamental safety protocols when faced with a real-world situation.
Immediate Jeopardy Designation and Removal
State surveyors initially designated this deficiency as "Immediate Jeopardy"—the most serious category of nursing home violation, indicating a situation that has caused or is likely to cause serious injury, harm, or death to residents. This designation reflected the critical nature of the facility's failure to protect a resident who had expressed intent to self-harm.
The facility implemented a comprehensive plan of correction to address the immediate jeopardy, which was verified and removed on January 5, 2025. However, the facility remained out of compliance at a lower severity level, as surveyors noted the need to evaluate the effectiveness of the newly implemented corrective systems over time.
The corrective measures included daily review of 24-hour reports and facility activity logs to identify any residents expressing or indicating suicidal ideation, validation that appropriate assessments and notifications were completed for any identified cases, assignment of responsibility to the Director of Nursing or designee for weekday monitoring and to weekend supervisors for weekend coverage, and notification of the Medical Director about the immediate jeopardy finding and corrective actions.
Additional Issues Identified
Beyond the primary findings related to suicide prevention protocols, the inspection documentation revealed broader concerns about the facility's crisis response systems and quality assurance processes. The facility conducted an Ad Hoc Quality Assurance and Performance Improvement meeting on January 3, 2025, to address the deficiencies—a reactive measure taken only after the inspection identified serious problems.
The Director of Nursing reviewed facility activity reports and 24-hour reports dating back to January 1, 2025, to identify any additional residents who had voiced suicidal ideation. This retrospective review found no other cases, but the fact that such a review was necessary highlighted the absence of ongoing systematic monitoring for mental health crises prior to the inspection.
The inspection process included psychiatric evaluation documentation showing that Resident #1 was diagnosed with anxiety as a primary condition and major depressive disorder (recurrent) as a secondary diagnosis. The psychiatric assessment noted staff reports of loss of interest and psychomotor agitation, though the resident stated "I'm fine" during the examination and denied current suicidal ideation at the time of the delayed evaluation.
The facility's response to the inspection findings demonstrated recognition of serious deficiencies in its mental health crisis management systems. The implementation of standardized assessment tools, comprehensive staff training, and daily monitoring protocols represented significant improvements to resident safety procedures. However, the inspection underscored the critical importance of immediate action when residents express suicidal thoughts—a fundamental principle of crisis intervention that should never require regulatory enforcement to implement.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Pavilion At Creekwood from 2025-01-05 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.