Suicide threats not heeded in Salem nursing home death

An 81-year-old resident who killed himself in a Salem nursing home had repeatedly mused about suicide in the days leading to his death, but health workers failed to act on a note about his suicidal thoughts tucked into medical records, state investigators found.

Federal regulators are sanctioning the Grosvenor Park Health Center, part of a troubled out-of-state chain, for not taking measures that might have prevented the suicide — a failure of action that resulted in “actual harm” to the resident. The regulators, however, have not disclosed what penalties the nursing home might face.

The resident shot himself with his legally registered .357-caliber Smith & Wesson handgun in August, two days after being admitted to Grosvenor Park, according to a newly released state report.

The investigation provided new details on the death, which was disclosed earlier. It found that staff members at the nursing home were aware of his suicidal thoughts, although the man at one point said comments he had made to relatives about wanting to die had been misunderstood.

Still, state investigators faulted nursing home staff members for either failing to notify colleagues about the resident’s suicidal thoughts, or not being aware they should have.

Grosvenor Park, one of 11 Massachusetts nursing homes owned by Synergy Health Centers of New Jersey, said in a statement that screening for suicide risk, depression, and mental health problems is a “clear, industrywide issue” for nursing homes.

“Since the August suicide of a recently admitted patient, the Grosvenor Park Health Center team has carefully reviewed the incident to determine lessons learned,” Synergy officials said in a statement. “In conjunction with feedback from [the state health department], we have focused on updating our processes to include more specific questions regarding mental health status and depression, better communications protocols, and improved staff education.”

Depression is a pressing problem in the nation’s nursing homes, with nearly half of residents diagnosed with the condition, according to a 2013 report from the US Centers for Disease Control and Prevention.

In the August case, the Grosvenor Park resident had talked about being depressed and having suicidal thoughts, according to accounts staffers later relayed to state investigators. But that information was never conveyed to the nurses caring for the resident, nor were staffers instructed to monitor him as his depression turned deadly, the report concluded.

The Grosvenor resident, who was in a wheelchair, said to a nurse practitioner on the morning he entered Grovesnor that he was feeling “a little depressed,” and asked the nurse practitioner how she would feel if she had just been told she would “never walk again,” the report said. The patient is not identified in the report because of patient confidentiality laws.

The report is based on state investigators’ interviews with the resident’s family and Grosvenor staff in the days after his suicide Aug. 26.

The nurse practitioner offered the resident counseling services when he said he was depressed, but he declined, according to the investigation.

Later that same day, another nurse told the nurse practitioner that a family member of the resident had relayed a troubling conversation. The resident told the family member about wanting to die.

The nurse practitioner then returned to the resident, saying she was concerned, and the resident told her he “felt embarrassed” that his earlier comments had “trickled back to her,” the report said.

The resident told the nurse practitioner he felt frustrated about his situation, but that his conversations with family had been a misunderstanding, and that comments he made about the financial impact on his relatives if he killed himself were misconstrued, according to the nurse practitioner’s recollections. The report did not indicate the nature of those financial concerns.

A note the nurse practitioner placed in the resident’s medical file indicated he was not “overly depressed,” but should continue taking medication for depression, and be monitored for “suicidal ideation.”

That’s where the situation unraveled, investigators found.

The nurse practitioner’s plan for monitoring the patient was limited to waiting for a physician’s evaluation two days later. The plan did not include promptly alerting the nursing staff who were caring for the resident, according to investigators.

A physician who visited with the resident the day he committed suicide wrote in the medical file that he seemed “pleasant,” and made no reference to the nurse practitioner’s note about the man’s earlier thoughts of suicide.

The physician later told investigators he found the resident to be “fine, jovial, not depressed, and not suicidal.” He also told investigators that physicians and nurse practitioners “moved on” if residents denied feeling suicidal, and that it was not appropriate to “browbeat a resident who made a statement suggestive of suicidal ideation when they might have just had a bad day.”

The physician acknowledged it was a violation of nursing home policy not to have staff monitor the patient after he expressed suicidal thoughts, according to investigators. The nurse practitioner who failed to alert other nursing staff later told investigators she was unaware that Grosvenor’s policy required her to do so.

Grosvernor Park has historically received high marks from state inspectors, and still ranks above average among Massachusetts nursing homes 15 months after Synergy purchased the longtime family owned facility, state records show.

About 10:20 p.m. Aug. 26, the man shot himself, while a roommate was on the other side of a curtain in the same room, the report said. Investigators did not address in their report how or when the resident acquired the handgun.

Nursing homes are required to report suicides to the state health department. But the agency was unable to say how many nursing home suicides have been reported in recent years and could find none since 2010 that might have involved a firearm.

Grosvenor’s director of nursing later told investigators he discovered the note in the resident’s medical file — 12 hours after the suicide — describing the family’s concerns about suicidal statements. It was, he said, the first time he had been aware the resident had spoken about killing himself.