Legal Issues| Volume 20, ISSUE 3, P11, April 2019

Admitting and Treating Patients With Mental Illness and a History of Self-Harm

      Due to the changing dynamic in the health care industry, the number and percentage of elderly patients admitted to skilled nursing facilities with mental illness (schizophrenia, bipolar disorder, depression, or anxiety) and dementia (along with the accompanying behaviors) will continue to increase in the next 10 years.
      This trend presents patient behavior challenges to SNFs, both in terms of resources and increased level of risk exposure. To adapt to the trend, SNFs need to ensure the correct decisions are made in deciding whether to admit a patient at the outset. They must determine whether they are able to provide the level of care required by the individual patient; if so, they must ensure appropriate patient-centric care plans are developed, implemented, and updated as needed. This is increasingly important now that SNFs are virtually obligated to readmit residents who have been discharged but want to return as soon as a bed becomes available, except in specific and unusual circumstances. The importance of frequent communication and a collaborative approach between the SNF and attending and consulting practitioners in the care of such patients is imperative, as outlined in the following case study.

      Case Study

      Mrs. W had a complex medical history, including long-standing psychiatric diagnoses of bipolar disorder with psychotic features and a history of self-harm. She’d had four prior incidents of self-harming behavior, including attempted suicide via slashing one or both wrists. The last incident had occurred just seven weeks before her admission to a SNF. She was admitted to the SNF directly from a secured psychiatric facility.
      Mrs. W committed an act of self-harm in the SNF — she cut and stabbed both her wrists with a metal eating utensil, resulting in significant blood loss. There was also a delay in finding her after the incident because she had been left unsupervised with the utensils in her room during meal service. The staff’s care plan had failed to provide one-person assistance or supervision during meals, despite the patient’s prior episodes of self-harm.
      Mrs. W was being followed closely by an external mental health therapy service. Before the incident at the SNF, her therapist had spoken with the director of nursing (DON) and expressed concern about the patient being left unsupervised with metal eating utensils. She also had reminded the DON about the patient’s history of self-harm.
      The resident’s records also demonstrated that her mental health therapy team had been aware of Mrs. W’s active suicidal and self-harming ideations in the days before her injury. Her mental health team had considered a further 5150 hold (involuntary due to being a danger to self or others) but ultimately had declined to initiate it. More importantly, the psychologist on the team had failed to report Mrs. W’s suicidal and self-harming ideation to the SNF staff. Had such communications been made, the outcome in the case probably would have been different. Significantly, the mental health therapy team was not named in the lawsuit, providing an “empty chair” defense and helping to reduce the overall exposure of the SNF in the case.
      The patient and her family sued the SNF for elder neglect, alleging among other things that the SNF had failed to properly assess the patient and failed to implement appropriate plans of care to address the potential for further episodes of self-harming behavior, which had culminated in her injuries.


      The primary issues in the case were the decision to admit the patient at the outset, followed by the failure to implement an appropriate activities of daily living care plan for feeding the patient with supervision. Finally, the SNF had failed to act immediately after warnings from the patient’s mental health therapist and from the patient herself, culminating in the episode of self-harm and the ensuing lawsuit.
      The big question for the SNF is whether it was able to provide the level of care required by Mrs. W, immediately after her discharge from a secured psychiatric facility and just several weeks after she had caused self-harm in a prior incident.
      The physician who had assessed the patient upon her admission to the SNF did not issue specific orders for supervision of the patient during her meals or preventing Mrs. W from having metal silverware, despite the fact that she had a recent history of using similar metal instruments to engage in self-harming behavior.
      Given the patient’s history of self-harm, the decision to replace metal eating utensils with plastic eating utensils should have been a straightforward one. Investigation revealed the system for communicating such requests to the SNF’s kitchen was rudimentary and deeply flawed, at best.
      Mrs. W’s injury was ultimately the result of a breakdown in communication at multiple levels and between various care providers, specifically her mental health therapy team, who failed to report her suicidal ideation to emphasize the urgency of their recommendation for one-to-one (1:1) supervision and the removal of metal eating utensils during meals; and her primary care physician, the SNF team, and the DON, who failed to implement a timely, appropriate plan of care despite being forewarned of the issue.

      Best Practices

      • A preadmission assessment should have been considered to determine whether the SNF was capable of providing the level of care necessary for a geriatric psychiatric patient who had exhibited significant psychiatric behavior before admission to the SNF.
      • Although the SNF administrator had told the family that staff would not provide the 24-hour, 1:1 supervision that had been provided in prior acute facilities, this statement was not documented anywhere. Better charting would have memorialized this discussion before the resident’s admission. It’s also not clear that telling a patient or family that 1:1 supervision will not be provided can prevent liability if in fact at some point that appears to be the level of care that the resident requires; the regulations state (somewhat vaguely) that SNFs must be staffed “sufficient[ly] to meet the needs of the residents.”
      • The SNF team should have had much greater integration with the patient’s behavioral health services team and primary care physician from the date of admission by including representative(s) of her mental health therapy team in the interdisciplinary team and care-planning decisions.
      • One helpful approach is to establish regularly scheduled behavioral rounds for the mental health providers, social worker, and supervising registered nurse.
      • The number of psychiatric patients admitted should not overwhelm the SNF’s capability to appropriately address their needs.
      • In-service training should be implemented for staff to upgrade their skills to better understand and manage the emotional and behavioral issues of geriatric psychiatric patients. With Phase 3 of the new Requirements of Participation going into effect in November, SNFs will also need to train staff in trauma-informed care.
      • As always, proper documentation of these efforts is a must. Documentation may not prevent a lawsuit, but it will minimize the SNF’s risk and provide the best defense possible if a claim is made.
      This column is not to be substituted for legal advice. Mr. Wilson is a partner in the law firm Wilson Getty LLP, which represents all types of long-term care facilities against civil claims. He also represents facilities in administrative hearings and advises long-term care clients on risk management and corporate compliance.