Severe reports

Based on review of the internal incident report, the provider failed to implement prompt emergency care to Resident #1 after Resident #1 experienced a suicide attempt. There was a 9-minute period between the time Resident #1 was found after the suicide attempt and the provider decision to call EMS. Per video review of the incident, Resident #1 was discovered by Staff #1 and #2 at 5:01pm after the suicide attempt. Per the incident report, after a few minutes of asking Resident #1 questions, Staff #2 and Staff #6 made the determination that EMS personnel were needed and made a 911 telephone call. The incident report explained the call to EMS was not made until, "about 5:10pm," which was after the internal nursing staff was contacted.

From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-46-810. A. (3) The provider shall have and implement written procedures for promptly: 3. Providing emergency services for each resident;; 12VAC35-46-810. A. (4) The provider shall have and implement written procedures for promptly: 4. Providing emergency services for any resident experiencing or ....

Individual #1 was able to obtain large quantities of each medication from Employee #1’s personal belongings, and later ingest these medications while on the unit, which resulted in the individual being hospitalized and whom later died.

Therefore, Individual #1 had an opportunity to ingest Employee #1’s medications, which resulted in the individual being hospitalized, and whom later died.

From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-46-60. K. Providers shall not engage in willful action or gross negligence that jeopardizes the care or protection of residents.; 12VAC35-46-800. A. (2) There shall be evidence of a structured program of care designed to: 2. Provide protection, guidance, and supervision;.