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Nursing Home Fined over $85,000 for Failure to Address Suicidal Tendencies

A nursing home in Vermont was fined $85,940 in February, 2021 and placed in immediate jeopardy after a survey team found six deficiencies at the facility that presented a significant risk of serious harm or death as a result of noncompliance. Among the problems at the nursing home, the survey found that the staff didn’t follow doctors’ orders; were late distributing medicine; served cold food; didn’t bathe residents often enough; didn’t change bed linens often enough; and didn’t provide enough washcloths and towels.

However, the most serious problem was that one resident at the facility had suicidal tendencies yet the nursing home failed to notify the physician and the resident representative of this significant change in the resident's mental status, resulting in an ongoing risk of serious harm and/or death. The survey said that the facility didn’t notify the physician and the resident representative due to its failure to assess the resident's mental status and the safety of the resident's environment.

As a result, the survey cited the facility with F-Tag F580, which says that if there is a significant change in a resident’s physical, mental, or psychosocial status—that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications—the facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s).

In this particular case, the resident’s mental health status had clearly deteriorated, so the facility’s failure to notify the resident’s physician was a pretty egregious error. Besides this mistake, the nursing home in Vermont had a slew of other deficiencies, all of which could have been avoided—along with the financial penalty—if the facility had stayed on top of healthcare regulatory guidance.

There are numerous healthcare regulations pertaining to mental health at long-term care facilities (e.g. California’s AFL 20-38.7), and you can find them easily using the smart-search tool on our software. Sign up and start using software for free at and stay on top of the voluminous and fast-changing healthcare regulatory landscape.

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