SEO_DESCRIPTION: Mansfield nursing home faced immediate jeopardy citation after resident expressed suicidal thoughts without proper safety protocols being followed.
OG_TITLE: TX Nursing Home Hit with Immediate Jeopardy Over Suicide Prevention Failures
OG_DESCRIPTION: The Pavilion at Creekwood in Mansfield failed to implement mandatory one-on-one supervision when a resident voiced suicidal ideation, creating serious safety risks and prompting federal intervention.
FB_POST: BREAKING: Mansfield nursing home cited for immediate jeopardy after failing to protect suicidal resident with proper safety protocols.
ARTICLE:
MANSFIELD, TX - Federal inspectors issued an immediate jeopardy citation to The Pavilion at Creekwood after the facility failed to implement proper suicide prevention protocols when a resident expressed thoughts of self-harm.
The January 5, 2025 inspection revealed serious gaps in the facility's mental health crisis response procedures, specifically regarding a resident who had voiced suicidal ideation but did not receive the required immediate one-on-one supervision as mandated by federal regulations.
Critical Safety Protocol Failures
The inspection documented that when a resident expressed suicidal thoughts, nursing staff failed to implement the required immediate one-on-one supervision protocol. This represents a fundamental breakdown in suicide prevention procedures that could have placed the resident at serious risk.
According to federal regulations, nursing homes must have comprehensive suicide prevention policies that include immediate protective measures when residents express thoughts of self-harm. The failure to follow these protocols resulted in the most serious level of citation - immediate jeopardy - indicating inspectors determined the situation posed an immediate threat to resident safety.
The facility's own policy clearly outlined the required response: when a resident voices or indicates suicidal ideation, licensed nursing staff must implement one-on-one supervision immediately and notify the Social Services Director. If a safe environment cannot be maintained with this supervision, the resident should be transported to an acute care setting for evaluation and treatment.
Mental Health Crisis Management in Long-Term Care
Suicide prevention in nursing homes requires specialized protocols due to the vulnerability of the elderly population. Depression and suicidal ideation among nursing home residents occur at significantly higher rates than in the general elderly population, making proper crisis intervention procedures essential for resident safety.
The Columbia Suicide Severity Rating Scale, which the facility's Social Services Director was supposed to complete, is a standardized assessment tool designed to evaluate suicide risk. This evidence-based instrument helps healthcare providers determine the appropriate level of intervention needed to protect patients from self-harm.
When residents express suicidal thoughts, immediate protective measures serve multiple critical functions. One-on-one supervision ensures continuous monitoring to prevent impulsive self-harm attempts, while prompt psychiatric evaluation helps determine the underlying causes and appropriate treatment interventions.
Regulatory Response and Corrective Measures
The facility responded to the immediate jeopardy citation by implementing comprehensive staff re-education on suicide precaution management. All licensed nurses and the Social Services Director received training by January 4, 2025, covering proper response protocols when residents voice suicidal ideation.
The corrective plan included several key components designed to prevent future incidents. The Director of Nursing committed to reviewing daily reports in clinical morning meetings Monday through Friday, beginning January 5, 2025, to identify residents who may be experiencing suicidal thoughts and validate that proper assessments and notifications were completed.
Weekend supervisors received responsibility for conducting the same reviews during weekends, ensuring continuous monitoring of resident mental health status throughout the week. This systematic approach aims to catch potential crisis situations before they escalate.
Staff Training and Competency Verification
Following the citation, facility administrators conducted comprehensive suicide prevention training for 63 staff members across multiple departments. The training participants included 16 Licensed Vocational Nurses, 24 Certified Nursing Assistants, 8 Registered Nurses, the Medical Director, Activity Director, Housekeeping Supervisor, and various other personnel.
During follow-up interviews conducted on January 5, 2025, inspectors verified that staff from various shifts could properly verbalize the facility's suicide prevention policy. The interviewed staff demonstrated understanding of notification requirements and intervention procedures, including when to implement one-on-one supervision and when to consider transfer to acute care settings.
This comprehensive training approach reflects the facility's recognition that suicide prevention requires facility-wide awareness and competency, not just among clinical staff. Support personnel often interact regularly with residents and may be among the first to notice changes in mood or concerning statements.
Psychiatric Evaluation and Follow-up Care
The resident who initially expressed suicidal ideation underwent psychiatric evaluation on January 2, 2025. The psychiatry provider determined that hospital transfer was not appropriate at that time, and the resident agreed to continue treatment while remaining at the facility.
A subsequent psychiatric assessment documented that while staff reported symptoms of loss of interest and psychomotor agitation, the resident denied current suicidal ideation or thoughts of self-harm when directly questioned. The assessment identified anxiety as the primary diagnosis with major depressive disorder as a secondary condition.
The Social Services Director completed a suicide ideation assessment on January 3, 2025, determining that the resident was not deemed a threat to herself. This assessment process demonstrates the multi-layered approach required for proper evaluation of suicide risk in nursing home settings.
Immediate Jeopardy Resolution
Federal inspectors verified removal of the immediate jeopardy status on January 5, 2025, after confirming the facility had implemented required corrective measures. However, the facility remained cited at a lower level of non-compliance, requiring continued monitoring to evaluate the effectiveness of the new safety systems.
The inspection team noted that while immediate dangers had been addressed, ongoing oversight was necessary to ensure the facility's corrective measures would prevent similar incidents in the future. This approach allows facilities to demonstrate sustained compliance with suicide prevention requirements.
An Ad Hoc Quality Assurance and Performance Improvement meeting was held on January 3, 2025, and the Medical Director was notified of the immediate jeopardy citation and the facility's corrective plan contents.
Industry Standards for Mental Health Care
Effective suicide prevention in nursing homes requires integration of multiple clinical disciplines and systematic monitoring procedures. Research indicates that elderly nursing home residents face elevated suicide risk due to factors including chronic illness, functional decline, social isolation, and adjustment difficulties related to institutional placement.
Evidence-based suicide prevention programs emphasize early identification of risk factors, prompt clinical assessment, and implementation of appropriate safety measures. The use of standardized assessment tools like the Columbia Suicide Severity Rating Scale helps ensure consistent evaluation of suicide risk across different staff members and shifts.
Proper documentation of mental health assessments and interventions also serves important clinical and regulatory functions, providing a clear record of the facility's response to mental health crises and enabling continuity of care across different healthcare providers.
The citation at The Pavilion at Creekwood highlights the critical importance of having robust suicide prevention protocols and ensuring all staff understand their roles in protecting vulnerable residents during mental health crises.
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.
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