Failure to Prevent Involuntary Seclusion of a Resident
Penalty
Summary
The facility failed to prevent involuntary seclusion for one resident, as evidenced by staff actions and resident reports. According to the clinical record, the resident had diagnoses including anxiety, depression, and psychotic disorder, and was assessed as cognitively intact but functionally dependent. During an observation, the resident was found with their door closed, repeatedly yelling to have it opened. A nurse aide admitted to closing the door because the resident was yelling and instructing her, and this was confirmed by a licensed practical nurse who instructed not to shut the resident's door. The resident reported that the door was shut for about five minutes, and that the nurse aide closed it while on the phone and passing lunch trays. Facility policy prohibits involuntary seclusion, defined as separating a resident from others or confining them to their room against their will. Interviews with the resident, the nurse aide, and facility leadership confirmed that the door was closed against the resident's wishes, constituting involuntary seclusion. The incident was corroborated by direct observation and staff statements, and the facility's failure to prevent this action was acknowledged by the nursing home administrator and director of nursing.