Failure to Prevent Involuntary Seclusion Due to Improper Secure Unit Placement
Penalty
Summary
The facility failed to ensure that a resident was free from involuntary seclusion and physical restraint not required to treat medical symptoms. A female resident with severe cognitive impairment, dementia, and heart failure was admitted and later placed on a secure unit. Documentation showed that initial elopement risk assessments indicated no risk, and there was no evidence of behavioral symptoms such as wandering or exit-seeking prior to her transfer. The resident's care plan and medical record did not contain orders or clear documentation justifying her placement on the secure unit at the time of transfer. Interviews with staff, including CNAs and LPNs, revealed that the resident had not exhibited exit-seeking behaviors or attempts to elope. Staff described her as forgetful and easily redirected, with occasional wandering only when searching for misplaced items. The resident herself did not express distress about her placement and participated in activities, but her family was not informed about the reason for her move to the secure unit and requested her return to the general population. The care plan was updated to reflect elopement risk only after the investigation began, and the elopement risk evaluation with a moderate risk score was not completed or available in the electronic medical record until after the surveyor's inquiry. Facility leadership, including the ADON and DON, could not provide consistent or documented reasons for the resident's placement on the secure unit, and there was no physician order for the move. The facility's policy on wandering and elopement did not specify criteria or procedures for secure unit placement. The lack of proper assessment, documentation, and communication regarding the resident's transfer to the secure unit constituted a failure to protect the resident from involuntary seclusion.