MARLBOROUGH, MA - Federal inspectors found that Marlborough Hills Rehabilitation & Health Care Center failed to implement adequate suicide prevention measures for a resident with a documented history of self-harm attempts, resulting in two separate incidents where the individual accessed prohibited items and attempted self-injury.
Multiple Safety Plan Failures
The inspection revealed systematic failures in the facility's suicide prevention protocols for a resident who had recently attempted suicide on March 28, 2025. Following the resident's return to the facility, staff developed a comprehensive care plan on April 3 that included specific safety interventions: psychotherapy sessions, frequent staff rounds, and continuous psychosocial monitoring.
Despite these measures, the resident accessed a plastic knife on April 5 and inflicted a superficial cut to their forearm while making continual suicidal statements. The individual was transported to the hospital emergency department for evaluation and returned to the facility five days later.
Care Plan Modifications Prove Insufficient
Following the plastic knife incident, facility staff updated the resident's care plan on April 11 to include one-on-one monitoring during meal times. This modification specifically addressed the need for direct staff supervision when the resident had access to eating utensils.
However, on May 8, the resident again accessed prohibited items, this time obtaining a metal fork. The individual broke off three of the four prongs and attempted to stab themselves with the modified utensil. Emergency medical services transported the resident to the hospital for evaluation, and they returned to the facility that same evening.
Medical Significance of Prevention Failures
Suicide prevention in long-term care facilities requires multiple layers of protection, particularly for residents with documented self-harm behaviors. The repeated access to potentially dangerous items indicates fundamental gaps in environmental safety controls and staff supervision protocols.
When residents demonstrate suicidal ideation, medical standards require comprehensive risk assessment and implementation of appropriate safety measures. These typically include removal of potential self-harm objects, enhanced monitoring, and therapeutic interventions designed to address underlying mental health concerns.
The facility's failure to prevent repeated access to dangerous items despite known risks represents a significant departure from established suicide prevention protocols in healthcare settings.
Inadequate Response to Escalating Risk
Following the second incident, facility staff implemented 15-minute safety checks for 72 hours only. The Director of Nurses acknowledged during the inspection that despite the care plan interventions prohibiting access to metal utensils, the resident was able to obtain silverware on multiple occasions.
Federal regulations require nursing homes to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This includes implementing effective measures to prevent foreseeable harm, particularly for vulnerable residents with documented mental health risks.
Industry Standards and Best Practices
Effective suicide prevention in long-term care facilities typically involves comprehensive environmental assessments to identify and remove potential self-harm objects, implementation of appropriate monitoring levels based on individual risk factors, and coordination with mental health professionals to address underlying psychiatric conditions.
Standard protocols also require regular reassessment of safety measures and modification of interventions when initial approaches prove ineffective. The repeated incidents at Marlborough Hills suggest inadequate evaluation and adjustment of the resident's safety plan despite clear evidence that existing measures were insufficient.
Regulatory Violations and Oversight
The inspection, conducted on May 21, 2025, classified this deficiency under federal tag F656, which addresses the facility's obligation to provide necessary care and services. Inspectors determined the violations resulted in minimal harm or potential for actual harm, affecting few residents.
The facility must submit a plan of correction detailing specific measures to prevent similar incidents and ensure appropriate suicide prevention protocols for all residents with documented mental health risks.
This case highlights the critical importance of robust safety protocols and environmental controls in long-term care settings, particularly for residents with complex mental health needs requiring specialized interventions and continuous monitoring.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marlborough Hills Rehabilitation & Hlth Care Ctr from 2025-05-21 including all violations, facility responses, and corrective action plans.
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