Complaint Investigation Report

Allegation: Facility did not seek timely medical assistance resulting in client’s death

It was alleged that Resident #1 (R1) requested to be placed on a 5150 hold on or around 07/16/2023, but their request was denied by facility staff which ultimately resulted in their death on 07/21/2023. An audio recording was obtained. Staff #1 (S1) was asked why R1 was not placed on a “suicide hold,” the days prior to their death and S1 stated, “I don’t know”

Interview with S1 revealed that they were working on Sunday 07/16/2023. S1 stated that R1 did say they wanted to kill themselves but did not verbalize a plan of action on how they would kill them themselves. On 07/16/2023, R1 was crying because their parent would not answer the phone, they were missing their child and had expressed displeasure with their roommate. R1 eventually reached their parent on the telephone. S1 spoke to R1s parent and advised that they had no control over room changes and that they would have to speak to the Licensee the next day. After the conversation with R1s parent, R1 mentioned to S1 “I want to kill myself.” After calming down, R1 did not exhibit or display any other behaviors. S1 stated, “after I checked on R1 that night to make sure they were okay.” S1 could not explain the “suicide hold” that is mentioned in the audio recording and stated, “R1 wasn’t talking about suicide hold,” and “parent wasn’t saying anything about suicide.” If R1’s parents said R1 was suicidal, S1 stated they would call 9-1-1 and watch over the resident. S1 called Staff #2 (S2), who is their spouse, and stated, “S2 call the Licensee to tell them what R1 said,” and S2 said that they were going to. S2 never got in contact with Licensee. When being relieved that evening, S1 told Staff #3 (S3) what R1 said about wanting to kill themselves and added, “when I left, R1 was on their bed sleeping.” S2 stated they did not receive a phone call from S1 on 07/16/2023 about R1, and added “S1 told me R1 wanted to kill themselves, to call the Licensee. I called the licensee after. The Licensee never answered the phone.” S3 could not recall if anything was relayed to them by S1 about R1 on 07/16/2023 during the shift changeover.

Licensee stated that they were not contacted by the staff for a 5150 hold for R1 and stated, “don’t remember any 5150 with R1.” They added if a resident’s condition is not life threatening, “it’s a waste. It doesn’t meet the criteria. I have to call the psych to get their opinion,” and “it’s up to our knowledge. Does it need to be hospitalized? It’s our call,” and “sometimes the residents need the attention. It’s a waste of everyone’s time. They’re sending back the same day,” and “but R1 never had a behavior problem.”