Failure to Obtain Physician Order and Assessment for 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 male resident with diagnoses including Alzheimer's disease, muscle wasting, chronic kidney disease, and hypertension was admitted and subsequently moved to a secure/locked unit. Documentation revealed that prior to the transfer, there was no physician order, no documented clinical criteria for secure unit placement, and no evidence of exit-seeking or wandering behaviors in the resident's assessments or care plan. The resident's Minimum Data Set (MDS) at admission indicated moderate cognitive impairment but no behavioral symptoms such as wandering, and no elopement risk evaluation was found in the electronic medical record. Interviews with facility staff, including the Director of Nursing Services (DNS) and the Administrator, indicated that secure unit placement should be based on exit-seeking behavior and require both an assessment and a physician order, as well as family consent. However, the DNS could not locate the required assessment or documentation supporting the transfer, and the Administrator was unsure if the behaviors leading to the transfer were documented. The facility's policy required interdisciplinary team review and a physician order for secure unit admission, but these steps were not followed in this case. The resident's family member reported being notified of the move after it occurred and stated that she did not consent to the transfer. She also indicated that the facility did not attempt alternative interventions before moving the resident and that some of the resident's personal property was removed due to safety concerns in the secure unit. The family ultimately requested the resident's discharge from the facility. There was no documentation of a decline or negative impact on the resident as a result of the transfer, but the required assessments, orders, and consents were missing from the record.