Resident Subjected to Involuntary Seclusion Due to Bed Placement
Penalty
Summary
A deficiency occurred when a resident with severe intellectual disabilities, spastic quadriplegic cerebral palsy, tracheostomy, and gastrostomy status was subjected to involuntary seclusion. The resident, who required 1:1 supervision when up in his wheelchair due to lack of self-mobility and safety awareness, was placed in isolation for rhinovirus and was not to be left unattended in his room. On the day of the incident, staff positioned the resident's bed in such a way that it blocked the resident from exiting his room freely while he was in his wheelchair. Multiple staff interviews confirmed that the bed was intentionally placed to prevent the resident from leaving the room, with some staff believing this was an acceptable practice during isolation precautions. The resident was visible from the window, but did not have the ability to leave the room independently due to the bed's placement. The care plan specifically required direct supervision and prohibited leaving the resident unattended when up in his wheelchair, but this was not followed. The incident was observed by a nurse manager during rounds, who found the resident blocked in his room and subsequently moved the bed. Staff involved in the incident acknowledged the bed was positioned to restrict the resident's movement, and there was a lack of clarity among some staff regarding the appropriateness of this action. The event was documented and reported, and the facility's investigation confirmed that the resident was involuntarily secluded by staff action.