Involuntary Seclusion and Resident Harm Due to Locked Unit
Penalty
Summary
Residents in the Med Bridge unit were subjected to involuntary seclusion when a portion of the unit was locked, restricting their ability to move freely. This action was initiated following an elopement incident, and as a result, 15 residents were confined behind a locked door without documented clinical justification for such restriction. Among these, three residents with intact or moderately impaired cognition confirmed they did not have the code to exit and required staff assistance to leave the unit. There was no evidence in their records indicating a need for placement in a secure, locked environment. The remaining residents were not interviewable and also lacked documentation supporting the necessity for such confinement. One resident experienced significant distress due to the locked environment, resulting in self-inflicted physical harm while attempting to exit the unit. This resident was observed banging on the locked doors and subsequently sustained acute fractures, requiring hospital treatment. Staff interviews confirmed that the locked unit was established as a temporary measure for wandering residents, but no individualized assessments or documentation supported the restriction for the affected residents.