Failure to Prevent Involuntary Seclusion and Unauthorized Restraint
Penalty
Summary
Facility staff failed to protect a resident's right to be free from involuntary seclusion. The incident involved a male resident with severe cognitive impairment, major depressive disorder, anxiety disorder, unspecified dementia, and Alzheimer's disease. The resident had a history of elopement and was admitted to a secure unit. On the day of the incident, the resident exhibited behaviors such as wandering into other residents' rooms, taking items, and becoming agitated when items were removed from him. He escalated to physically aggressive behaviors, including pushing a bedside table into a nurse, swinging a call light cord with a metal prong, and chasing staff down the hallway. Staff responded by physically restraining the resident, carrying him by his extremities without supporting his back or midsection, and placing him in his room. They then held the door closed, preventing him from leaving, while he struggled to get out. During the incident, staff did not attempt de-escalation techniques or remove other residents from the area as outlined in the resident's care plan. Instead, they focused on isolating the resident in his room and physically restraining him. The staff took turns holding the door closed, and the resident was left unsupervised inside the room, where he continued to display agitation, including breaking a window. The police and EMS were eventually called, and the resident was further restrained by law enforcement and administered medication by a hospice nurse. Interviews with staff revealed that the decision to seclude and restrain the resident was made collectively, and some staff expressed discomfort with the way the situation was handled. The facility's policies prohibit the use of unauthorized restraints and involuntary seclusion. However, staff actions during the incident did not align with these policies. The Director of Nursing and Administrator were not fully informed of the severity of the incident until after reviewing video footage. The resident's power of attorney was not notified in a timely manner, and there was no documentation of consent for the use of restraints or medication. The incident resulted in skin tears to the resident's finger and arm, and the resident was unable to recall the event during subsequent assessment.
Removal Plan
- Staff members LVN A, RN and NA were immediately suspended by the administrator. All three staff members remain suspended.
- Resident #1 had a head-to-toe assessment completed by the charge nurse. The skin tears to resident #1's finger and upper arm are being treated according to physician orders.
- Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts.
- The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents.
- Safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted.
- Head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses.
- Staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility.
- The medical director was notified of the immediate jeopardy by the Administrator.
- An ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal.
- The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies: Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement; All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse; Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent; Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement; Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident; Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe; De-escalate the behavior by giving the resident space; Monitor the residents from a safe distance; Provide 1:1 monitoring until further directed by the abuse coordinator; Staff will not restrain a resident or seclude a resident involuntarily.
- The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment: Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement; All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse; Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent; Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement; Trauma informed Care to include unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma; Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe; De-escalate the behavior by giving the resident space; Monitor the residents from a safe distance; Provide 1:1 monitoring until further directed by the abuse coordinator; Staff will not restrain a resident or seclude a resident involuntarily.