Failure to Prevent Involuntary Seclusion During Covid Exposure Precautions
Penalty
Summary
A resident with quadriplegia, congestive heart failure, and chronic obstructive pulmonary disease was placed on isolation precautions after their roommate tested positive for Covid. Despite testing negative and showing no symptoms, the resident was not allowed to leave their room, even when wearing appropriate PPE, and was not evaluated for mask use or compliance. The facility's infection preventionist and nursing staff were unable to correctly identify CDC recommendations for cohorting or the appropriate use of source control, and there were no physician orders directing isolation or specific precautions for the resident. The resident was observed alone in their room, behind a privacy curtain, without a mask or access to engaging activities, and expressed distress over missing religious services. Staff interviews revealed a lack of clarity regarding when the resident could leave the room, and the infection preventionist stated that no activities could be offered during the isolation period. The director of recreation confirmed the resident had not participated in or been offered any activities since the exposure. The director of nursing services stated it was unsafe for the resident to leave the room, despite staff being able to enter and exit with masks, and acknowledged the resident had not been trialed for mask use. The administrator was not aware of the resident's request to leave the room and recognized that restricting the resident could be considered involuntary seclusion. The facility's operational guide indicated exposed residents should be monitored, tested, and wear masks, but did not support the level of restriction imposed.