Resident Subjected to Involuntary Seclusion During Behavioral Episode
Penalty
Summary
A deficiency occurred when a resident with severe dementia, anxiety disorder, cognitive communication deficit, and other medical conditions was subjected to involuntary seclusion. During an episode of behavioral disturbance, the resident became verbally agitated, exhibited signs of psychosis, and physically aggressive behaviors, including grabbing and scratching a CNA and attempting to strike staff with a call light. In response, staff removed the resident from their room and transferred them to the community dining room while the resident was only wearing a soiled brief and a t-shirt. Once in the dining room, staff closed the door, isolating the resident from others, and observed the resident through the windows with the curtains drawn back. The resident continued to display agitated behaviors, such as attempting to rip the television from the wall, swinging the television cord at staff, and throwing objects. Staff offered food, drink, and medication, with the resident eventually accepting medication and calming down. The resident was then returned to their room. Facility documentation and interviews confirmed that the resident was left alone in the dining room with the door closed, separated from other residents, and exposed to view while in a state of distress and undress. The facility's own policies and resident rights documents define involuntary seclusion as the separation or isolation of a resident against their will, which occurred in this incident. The DON acknowledged that the situation was handled poorly and that the resident was isolated from the community during the episode.