JEFFERSON CITY, Mo.-
A St. Louis assisted-living facility where a resident’s death went unnoticed for 13 hours was routinely understaffed at night and failed to appropriately monitor several residents who had voiced suicidal intentions, according to state inspectors.
The January suicide at Autumn View Gardens was made public Thursday by state Rep. Sam Page, who urged the attorney general’s office to seek penalties against the facility.
The resident, who is not named in Department of Health and Senior Services documents, suffered from severe depression and recently had been hospitalized after expressing an intent to commit suicide. But upon release back to Autumn View Gardens, the facility failed to monitor the resident or develop a plan addressing the person’s suicidal tendency, said a memo from the health department’s long-term-care program manager, William Koebel.
Staff members found the resident dead in a bathroom on the morning of Jan. 16, about 13 hours after they had last seen the resident alive, according to health department records provided Thursday to The Associated Press.
Autumn View Gardens staff also failed to monitor or notify physicians about two other residents who had voiced suicidal thoughts, Koebel’s memo said.
Department inspection records show the facility was understaffed on 16 of the 20 nights reviewed in January. It was unclear if that was the case on the night of the suicide.
The Jan. 23 inspection also found a staff member asleep on a lobby sofa and indicated that one resident’s call light had been on for more than an 1 1/2 hours without anyone responding.
Autumn View Gardens administrator Betty Vick referred questions Thursday to facility operator Bethesda Foundation Inc., based in Colorado Springs, Colo. Julie Callender, the company’ senior vice president, declined to comment.
Page was notified of the violations last month because the facility is in his district. He called the facility’s lack of residential oversight appalling.
“I’m all for assisted living facilities and the services they provide,” Page said Thursday. “But there are reasons there are staffing rules, and this is an example, when the staffing rules aren’t followed, people get hurt.”
A plan of correction signed by Vick and submitted to the state in February said the facility was hiring more staff. It also said employees were advised to check on residents expressing suicidal intentions every hour and to immediately notify a physician.
Health department spokeswoman Nanci Gonder said a follow-up visit Feb. 13 by inspectors found the facility to be in compliance with staffing guidelines.
The department has not decided whether to recommend that Attorney General Jay Nixon seek a civil penalty against the facility, Gonder said.
Under Missouri law, a judge can order a civil fine of between $1,000 and $10,000 for the type of violation for which Autumn View Gardens was cited.
Nixon spokesman John Fougere said the office just learned Thursday of the matter and was beginning an immediate review.
