Failure to Prevent Involuntary Seclusion of Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect two residents from involuntary seclusion, as evidenced by two separate incidents involving residents with severe cognitive impairment and a history of dementia and agitation. In the first case, a resident identified as an elopement risk and known to wander was found to have been intentionally restricted from accessing certain areas. An agency Certified Nursing Assistant (CNA) closed one side of a fire door and blocked the other side with a mechanical lift, effectively confining the resident to a specific area to prevent entry into other residents' rooms. This action was observed by the Maintenance Assistant, who immediately reported the obstruction. In the second incident, another resident with Alzheimer's disease and a history of physical aggression was subjected to involuntary seclusion by a Resident Assistant (RA). The RA was observed by two staff members taking the resident to her room and shutting the door after the resident became agitated and physically aggressive. The resident was heard yelling for help, and another CNA intervened to assist her. Prior to the incident, the resident had been sitting quietly at the nurses' station, and the RA's actions were attributed to anger over the resident's earlier behaviors. Both residents involved were severely cognitively impaired, ambulatory, and wore wander guard alarms. The facility's own policies defined involuntary seclusion as separating a resident from others or confining them to their room against their will, except in short-term, monitored, therapeutic situations. In both cases, staff actions did not align with these guidelines, resulting in the residents being involuntarily secluded.