Resident Placed on Secured Unit Without Required Authorization or Consent
Penalty
Summary
The facility failed to ensure that a resident placed on a secured behavioral unit met the established criteria for admission to that unit. Specifically, the resident had diagnoses including subdural hemorrhage, intracranial injury, hypotension, generalized anxiety disorder, and impaired cognition, and was identified as being at risk for elopement and wandering. The care plan indicated the resident resided on the secure unit for safety, with interventions to manage wandering behaviors. However, there was no physician order authorizing the resident's placement on the secured unit, and the resident had not signed a consent form for this placement. Further review revealed that the resident had not been declared incompetent, nor did they have a power of attorney or guardian. The facility's policy required that residents admitted to the secure behavioral unit must have a current mental health diagnosis, psychosocial or behavioral disturbance, be deemed incompetent by a physician, and have a current or active power of attorney or guardian. These requirements were not met in this case, as confirmed by staff interview and medical record review.