Resident Involuntarily Confined to Room by Staff
Penalty
Summary
A deficiency occurred when a certified nurse aide confined a resident to their room by wedging disposable washcloths in the doorframe, preventing the resident from exiting. The incident was captured on surveillance video, which showed the aide following the resident to their room, closing the door, and placing the washcloths to block the door. The resident, who had diagnoses including Alzheimer's disease, Parkinsonism, and bipolar disorder, and was assessed as requiring maximal assistance with toileting, was left alone in the room for over two hours without the ability to leave or call for help. The resident was discovered by housekeeping staff, who found the door difficult to open due to the washcloths. Upon entering, they observed the resident unclothed except for a pair of pants pulled over their chest, with urine and feces present on the floor, beds, garbage can, and nightstand. The resident appeared anxious to leave the room, quickly exiting once the door was opened. The care plan for this resident indicated a risk for victimization and required monitoring for anxiety and protection from abuse, but these interventions were not followed at the time of the incident. Interviews with staff revealed that the nurse aide responsible for the seclusion did not deny the act and claimed to have been trained in this manner. Other staff members, including nursing and housekeeping, were unaware of the incident until after it was discovered. There was no physician's order for seclusion, and the event was not reported to law enforcement. Documentation of follow-up assessments by social work was lacking, and the incident was not discussed in the facility's Quality Assurance and Performance Improvement meeting.