Complaint Investigation Report

It was alleged that staff failed to provide proper care and supervision to a resident having suicidal ideation. LPA reviewed a sample of eight (8) resident files and gathered various documents, including but not limited to: the staff roster with contact information, resident roster, resident admission agreements, physician reports, care plans, narrative charting, progress notes, and communication log. In addition, the LPA interviewed the Executive Director (ED), seven (7) staff members, and eight (8) residents. All seven staff members stated that if a resident expresses any suicidal ideation, they are trained to ask leading questions, help redirect the resident to understand their thoughts better, and immediately report the situation to the ED or director, who would then contact the Union City Police Department. All eight (8) residents interviewed stated that staff provides appropriate care and supervision whenever residents express—or if they were ever to express—suicidal ideation to staff or anyone else. One resident (R1) clarified, “I do not have any suicidal ideation thoughts. I called the crisis team to talk, but I never mentioned that. I am mad that people keep on asking.” R1 stated, “staff do their round check and check in with me every hour”.