Involuntary Seclusion and Removal of Mobility Device
Penalty
Summary
A deficiency occurred when a resident with dementia and a history of falls was subjected to involuntary seclusion and had her wheelchair, her only means of mobility and safe transfer, taken away by a CNA. The resident was placed in her bed, her wheelchair was removed from her reach, and her room door was closed, leaving her unable to transfer or move safely. Multiple staff members observed or were informed of the incident, with some hearing the resident calling for help and expressing distress at being left without her wheelchair. The resident was visibly upset, crying out in fear, and reported pain in her shoulder following the incident. The resident's care plan specifically required that assistive devices be kept at bedside due to her high risk for falls and impaired cognition. Despite this, the CNA removed the wheelchair after a verbal altercation, and the resident was left in bed without means to get up or move independently. Staff interviews confirmed that the wheelchair was left outside the room and that the resident was yelling for help. The incident was not immediately reported by all staff, and some staff expressed concern that the action constituted a restraint and involuntary seclusion. The facility's own policy prohibits abuse, neglect, and involuntary seclusion, and staff, including the DON, acknowledged that removing a resident's wheelchair in this manner would be considered abuse or seclusion. The resident experienced emotional distress, pain, and fear as a result of being left without her wheelchair and confined to her room. The incident was reported to the administrator and law enforcement, and multiple staff statements corroborated the sequence of events that led to the resident's involuntary seclusion and emotional harm.