Resident Seclusion and Barricading in Dining Room
Summary
The facility failed to provide an environment that enhanced the quality of life for its residents, resulting in a serious deficiency. A vulnerable and severely cognitively impaired resident was found secluded in the dining/day room of a secured unit with the doors closed and blocked by two wheelchairs. This incident occurred when a staff member made rounds early in the morning and discovered the resident unable to exit the room. The resident, who had been admitted with Alzheimer's Disease, Dementia, and Anxiety, was found in this situation without any staff present initially, raising concerns about unreasonable confinement and involuntary seclusion. The incident was reported by a staff member who found the resident and immediately removed the wheelchairs to let the resident out. The staff member then educated the present staff about the inappropriateness of barricading residents. The LPN on duty admitted to placing the resident in the room to prevent her from disturbing a new admission, despite the availability of a CNA who could have supervised the resident. This practice of barricading residents in the dining room was reportedly observed on multiple occasions by another LPN, who noted that it was done to prevent residents from waking others. Interviews with staff revealed that the practice of using wheelchairs or medication carts to block the dining room doors was not an isolated incident. It was reported that this had been occurring over several months, with multiple residents being confined in the dining room during night shifts. The facility's policy on protecting residents from abuse, including unreasonable confinement, was not adhered to, leading to the citation of Immediate Jeopardy for substandard quality of care.
Penalty
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The facility failed to properly position residents during meals, affecting three individuals on the secured unit. Observations showed residents in tilt wheelchairs at inappropriate angles and one resident in a low wheelchair without leg rests, unable to reach their meal. Staff did not intervene to reposition the residents, and interviews confirmed the improper positioning. The facility's policy on dignity and respect was not followed.
Improper Positioning of Residents During Meals
Penalty
Summary
The facility failed to ensure proper positioning of residents during meals on the secured unit, affecting three residents. Observations revealed that two residents were seated in specialty tilt wheelchairs at angles between 60 to 75 degrees, with one resident's table height reaching their chin throughout the meal. The staff did not intervene or reposition the residents during the meal observation. Another resident was observed sitting in a low wheelchair without leg rests, with their feet dangling, and was not positioned properly at the table during breakfast. Despite staff presence, no intervention was made to reposition the resident to allow proper access to their meal. Interviews with staff confirmed the improper positioning of residents during meals. One staff member acknowledged that a resident was not positioned correctly at the table, citing concerns about the resident grabbing items off the table. The Director of Nursing verified that residents should be upright and properly positioned at an appropriate table height during meals. The facility's policy on Quality of Life - Dignity emphasizes care that promotes dignity, respect, and individuality, which was not adhered to in these instances.
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