Failure to Support Resident Choice and Prevent Involuntary Seclusion
Penalty
Summary
Staff failed to support a resident's right to self-determination and choice by not assisting her in leaving her room despite multiple requests. The resident, who had severely impaired cognition and was fully dependent on staff for wheelchair mobility, was observed repeatedly calling for help to leave her room. Staff locked her wheelchair brakes, preventing her from leaving, and did not attempt other interventions as outlined in her care plan, such as providing one-on-one support or moving her to a quieter area. The resident remained in her room calling for help until she was eventually removed for lunch service. On another occasion, staff again failed to assist her, and when she managed to leave her room independently, she was returned and her wheelchair was locked again. Interviews with staff and the resident's family confirmed that staff were aware of the need to assist dependent residents in leaving their rooms upon request and to try a variety of interventions if one failed. The family member reported previous concerns about the resident being left in her room with her wheelchair locked, describing it as being treated like a prison. Staff interviews revealed inconsistent application of interventions and an acknowledgment that the resident should have been assisted. Facility policy and the Director of Nursing confirmed that residents should be supported in exercising their rights and not subjected to involuntary seclusion.