LIBERTY, TX - Federal inspectors found severe deficiencies in suicide prevention protocols at Liberty Health Care Center after a resident attempted self-harm following inadequate supervision and care planning failures, according to a May 2025 inspection report.
Critical Breakdown in Suicide Prevention Led to Self-Harm Incident
The most serious violations centered on a resident with major depressive disorder who expressed suicidal thoughts on October 23, 2024, asking staff if the facility had helium because "I just want to kill myself." Despite the clear warning signs, the facility placed the resident on inadequate 15-minute monitoring checks rather than the continuous one-on-one supervision required for someone expressing suicidal ideation.
Between monitoring checks, the resident successfully cut her right wrist with a microblade razor she had ordered online. Staff discovered the self-harm incident during a routine 15-minute check, finding the resident with blood on her wrist and the razor in her left hand.
The facility's response revealed multiple system failures. Staff had not conducted a room search for potentially dangerous items when the resident first expressed suicidal thoughts, allowing her to retain access to the razor. The resident's care plan was never updated following the suicide attempt to address the ongoing risk of self-harm.
Medical protocols require immediate one-on-one supervision when any resident expresses suicidal ideation, regardless of whether they have a specific plan. This continuous monitoring prevents access to harmful objects and ensures immediate intervention if another attempt occurs. The 15-minute monitoring protocol the facility used creates dangerous gaps where vulnerable residents can act on suicidal impulses.
Inadequate Care Planning Following Mental Health Crisis
Following the October incident, the facility failed to develop a comprehensive care plan addressing the resident's suicide risk and mental health needs. Despite the resident being hospitalized for psychiatric treatment and returning to the facility in November 2024, her care plan remained unchanged until inspectors arrived in May 2025.
The facility's care plan policy required updates within 24 hours of any significant status change, including suicide attempts. Mental health status changes are particularly critical because they indicate fundamental shifts in a resident's psychological state and risk profile.
Proper care planning for residents with suicide risk requires specific interventions including environmental safety assessments, removal of potentially harmful objects, enhanced monitoring protocols, and coordination with psychiatric services. These elements create multiple protective barriers that prevent future self-harm attempts.
The resident had a complex medical history including stroke-related paralysis, diabetes, and multiple mood disorders including major depressive disorder, generalized anxiety disorder, and bipolar disorder. This combination of physical limitations and serious mental health conditions creates elevated suicide risk that requires specialized care approaches.
Staff Training Failures Compromised Resident Safety
The inspection revealed significant gaps in staff training on suicide prevention protocols. The licensed vocational nurse who discovered the self-harm incident reported he had not completed the facility's depression training and could not recall training on updated suicide policies. The social worker assigned to the case also could not recall receiving training on depression or suicide prevention.
Multiple staff members were unaware of policy changes implemented after the October incident. The facility updated its suicide prevention policy in November 2024 to require immediate one-on-one supervision for any expression of suicidal ideation, but staff had not been properly trained on these critical changes.
Industry standards require all nursing home staff to receive annual training on recognizing suicide risk factors, responding to suicidal ideation, and implementing safety protocols. This training must be updated whenever policies change, with competency testing to ensure understanding.
The training gaps created a dangerous situation where staff responsible for resident safety were unprepared to recognize warning signs or implement appropriate interventions. When residents with mental health conditions express distress, staff must be equipped to respond immediately and effectively.
Flawed Investigation of Staff Verbal Abuse Incident
In a separate but related violation, the facility failed to conduct a thorough investigation of verbal abuse between a housekeeper and a resident with dementia. The incident occurred during a smoking break when the housekeeper became aggressive about cigarette sharing, telling the resident "make me shut up" when the resident asked her to be quiet.
Multiple witnesses reported more severe verbal abuse than documented in the facility's investigation. One resident stated the housekeeper threatened to "whoop her ass," while another confirmed the aggressive language. However, the facility's investigation failed to interview all witnesses and did not capture the full scope of the verbal abuse.
Thorough investigations of alleged abuse must include interviews with all potential witnesses and comprehensive documentation of the incident. Incomplete investigations fail to establish the full pattern of inappropriate behavior and may miss opportunities to prevent escalation.
The facility suspended the housekeeper during the investigation and provided additional training on conflict management and resident rights. However, the incomplete investigation process raises concerns about whether other incidents of staff misconduct might be inadequately documented or addressed.
Additional Issues Identified
Inspectors documented several other concerns during the facility visit, including issues with abuse reporting timelines and staff understanding of mandatory reporting requirements. The facility had policies requiring immediate notification of abuse allegations, but some staff members were unclear about proper reporting channels and escalation procedures.
The inspection also revealed gaps in the facility's quality assurance processes. Regular audits of care plans and incident response procedures had not identified the failures in suicide prevention protocols or investigation procedures before the inspection occurred.
Environmental safety concerns included unlocked activity director offices where potentially dangerous materials like helium tanks were stored. While the activity director reported not having helium tanks at the time of inspection, the access control issues highlighted broader facility security concerns.
Federal inspectors classified the suicide prevention failures as "immediate jeopardy" - the most serious level of violation indicating substantial likelihood of serious injury or death. This designation was removed only after the facility implemented emergency corrective measures including comprehensive staff retraining, updated care plans, and enhanced monitoring protocols.
The facility has implemented corrective actions including facility-wide depression screening using the PHQ-9 assessment tool, mandatory staff training on suicide prevention, and weekly audits of high-risk residents. However, inspectors noted the facility remained out of compliance pending evaluation of these corrective systems' effectiveness.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Liberty Health Care Center from 2025-05-09 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.