Failure to Assess, Care Plan, and Obtain Consent for Secured Unit Placement
Penalty
Summary
The facility failed to properly assess, care plan, and document the placement of residents on a secured unit, as well as to obtain necessary consents and demonstrate that this setting was the least restrictive option. Observations over multiple days confirmed that the secured unit, identified as Station 2, required a code for egress, effectively restricting residents' ability to leave. For three sampled residents with varying cognitive and psychiatric diagnoses, there was no evidence in their clinical records, care plans, or physician orders that their placement on the secured unit was assessed, justified, or consented to by the residents or their representatives. For one resident with schizophrenia, bipolar disorder, and dementia, care plans and physician orders did not mention secured unit placement, and psychiatric notes indicated the resident was not a danger to self or others. Another resident with Alzheimer's dementia and schizoaffective disorder was assessed as not at risk for elopement, yet was placed on the secured unit without documentation of criteria or consent. A third resident with Lewy Body dementia and severely impaired cognition was also not assessed as an elopement risk, but was placed on the secured unit, with no documentation supporting the need for this level of restriction. Interviews with facility leadership, including the DNS, ADNS, and Medical Director, revealed a lack of established criteria or documented process for determining placement on the secured unit. The facility assessment did not identify the existence of a secured unit or criteria for placement, and the facility was unable to provide requested documentation such as placement consents or assessments. Residents interviewed were aware of their inability to leave the unit, and staff interviews confirmed that decisions for placement were made without formal guidelines or documentation.