Failure to Assess and Obtain Orders for Secured Unit Placement Resulting in Involuntary Seclusion
Penalty
Summary
The facility failed to ensure that residents placed in the secured mental health unit (MHU) had appropriate physician orders and assessments to justify their placement, resulting in involuntary seclusion. Specifically, two residents were found residing in the secured MHU without any documented orders or completed assessments to determine their appropriateness for this level of restriction. One resident had severely impaired cognition and was receiving hospice services, while the other was cognitively intact and reported feeling depressed and inappropriately placed in the secured unit. Both residents' records lacked evidence of the required admission process to the MHU. Interviews with facility staff, including the Director of Social Services, DON, and Administrator, confirmed that not only these two residents but also thirteen additional residents in the secured MHU did not have the necessary orders or assessments for their placement. Facility policy required the admissions team to screen and assess residents before placement in the behavioral unit, but this process was not followed. The facility's abuse prevention policy also stated that residents should be free from involuntary seclusion, which was not upheld in these cases.