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F0561
D

Failure to Honor Resident's Right to Choice During COVID-19 Isolation

Sebastopol, California Survey Completed on 04-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor a resident's right to self-determination and choice by not facilitating the resident's desire to go outdoors while in COVID-19 isolation. The resident, who had intact cognition and a history of anxiety and depression, became agitated in his isolation room and attempted to leave to get fresh air and sun. Multiple staff members, including the DON, IPN, and nurses, repeatedly asked the resident to return to his room, citing infection control protocols, despite the resident's escalating distress and requests to be outside. The staff did not provide the resident with personal protective equipment (PPE) or make accommodations to allow him to be outdoors safely, even though the facility's infection prevention nurse later acknowledged that residents on isolation could be outside with proper PPE. The resident's agitation increased after being asked to return to his room, leading to the administration of lorazepam for anxiety. Despite this, the resident continued to express frustration and attempted to leave his room again. Staff called 911 for assistance, and when police arrived, the situation escalated further, resulting in the resident becoming physical with an officer and being arrested. Interviews with staff indicated that the resident had not exhibited aggressive behaviors prior to this incident and that his anxiety and frustration were exacerbated by the isolation and lack of accommodation for his request to go outside. Record review showed that the resident had tested positive for COVID-19 but was not exhibiting significant symptoms at the time of the incident. The facility's policy stated that residents' autonomy and self-determination should be respected, but staff were not in-serviced on how to safely allow residents in isolation to go outdoors. The failure to support the resident's choice and provide reasonable accommodations contributed to the escalation of the incident.

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