Jihyun Park received the report in shift handoff that a resident was found early morning with a sheet wrapped around his neck and when asked what was wrong, the resident reported, “I am going to kill myself.” The outgoing RN reported notifying the CNO and leaving a message for the Psychiatrist also removing the sheet and having staff doing frequent rounds on this resident.

Park identified this as a safety risk for suicide attempts among residents in the CLC and did not feel safe monitoring the resident with 16 residents on the unit. She looked up the suicide policy and discovered there were no clear guidelines for managing residents with suicidal attempts/ideation in CLC. Ms. Park assessed the situation, called the provider, and the provider ordered a Psych crisis (Code Green) to be called. The on-call Psychiatrist responded immediately to assess the resident and transferred him to the ED for further, evaluation, subsequently, the resident was admitted for suicidal observation.

In addition, Ms. Park reached out to other CLC units, where numerous nurses expressed similar incidents of residents who attempted suicide and had no clear guidelines or policy. In addition, the GHH, nurses reported calling 911 because the psych crisis team does not respond to code green calls in the GHH and sometimes 911 leaves the resident stating the resident is not a danger it’s dementia. Ms. Park collaborated with CLC leadership, the clinical nurse educator, and the quality nurse department who conducted a root cause analysis. As a result, this led to a clear guideline for managing CLC residents with suicidal ideation and/or attempts. A SOP was created – SOP 56-114B-SOP-C11-001 Management of CLC Residents with Suicide ideations.