Inspectors from the Colorado Department of Public Health and Environment have cited a Colorado Assisted Living Facility for failing to conduct quarterly checks that could have revealed the resident possessed a weapon and for not taking action when the resident voiced thoughts of suicide.
The administrator of the assisted living facility allegedly tried to cover up evidence of safety lapses and missed warning signs that preceded a resident’s suicide in February 2021. Colorado state inspectors also said that the administrator attempted to hide or falsify information to make it appear staff had checked the resident’s room and had not reported his suicidal statements. It is uncertain at this time whether the administrator still works at the assisted living facility.
According to a report, the resident of the Colorado assisted living facility died on February 20, 2021, one day after staff said he had asked them to kill him. The resident had a history of depression, and staff members who the state inspectors interviewed anonymously said he mentioned dying by a specific method repeatedly in the months before.
A staff member told the state inspectors that she had filed an incident report that included the resident’s statement the day before he died. After the resident’s death, the statement was eliminated from the report. Other staff members said they had reported the resident’s statements about suicide in October and December 2020, and in January 2021. One staff member reported that the resident told her in February 2021 that he intended to die and that he would leave her some money.
At the time of the resident’s death, the administrator told state inspectors that she had never seen any specific reports that the resident was suicidal, and had told staff that they should listen respectfully to the resident’s feelings.
Five staff members also said they had not seen any room checks completed in February, and some said they had not been done for far longer. The administrator and another staff member told state inspectors that they had checked rooms. The state inspectors believed that the administrator attempted to fake documentation to make it look as though staff had checked the resident’s room recently.
A correction plan filed with the State of Colorado said that the assisted living facility will retrain staff and develop a policy to prevent suicides. The plan of correction also states that staff will check apartments quarterly, and the executive director will not be able to alter reports.
Issue:
All staff members should be aware of warning signs for identifying suicide risk and suicide ideation. Staff should be trained to immediately report these warning signs to leaders of the facility. The leaders should be knowledgeable in what to do if a resident is thinking about committing suicide, and must take all reports seriously. Additionally, leaders should be knowledgeable in what to do if a resident does attempt suicide or if they succeed in their suicide attempt.
Discussion Points:
- Review your policy and procedure on suicide prevention. Update as needed.
- Train all staff on identifying warning signs of suicide risk and suicide ideation. Additionally, train facility leadership on what to do if a resident is identified as considering suicide, and what to do if a resident attempts or succeeds at committing suicide. Document that the trainings occurred, and file each signed document in employee’s individual education file.
- Periodically audit staff understanding to ensure that they are knowledgeable in identifying warning signs of suicide ideation.
