Failure to Prevent Involuntary Seclusion and Incomplete Incident Investigation
Penalty
Summary
The facility failed to protect a resident's right to be free from involuntary seclusion, as required by its own Abuse Prohibition policy. During the night shift, a nursing assistant was found holding a resident's room door shut while the resident was inside, yelling to be let out and banging on the door. The nursing assistant admitted to holding the door closed because the resident was upset and the staff member felt scared. The resident, who had diagnoses including dementia, anxiety, and a recent fracture, was care planned for being resistive to care and at risk for behavioral issues, with interventions to redirect and allow time for composure. Despite these interventions, the staff member confined the resident to her room against her will. The incident was not immediately reported to the appropriate supervisor, and the initial investigation failed to include an interview with the RN Supervisor who was on duty at the time. The RN Supervisor did not initiate an investigation or assess the resident after the incident. The event was only reported to the RN Unit Manager during the following day shift, at which point a full body assessment was completed and no injuries were found. Staff interviews revealed confusion about which door was held shut, and the resident expressed feeling like she was being held hostage. The facility's investigation lacked timely and complete documentation, including omission of key staff interviews and immediate assessment.