Involuntary Seclusion of Two Residents by Barricading Beds
Penalty
Summary
The deficiency involves the involuntary seclusion and confinement of two residents to their beds by staff using physical barriers. One resident had bipolar disorder and a history of falling, and the other had hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, intellectual disabilities, and contractures. Facility reports documented that during early-morning rounds, the Activities Director observed that both residents’ beds, which were permitted to be placed against a wall with one open side, had the open side blocked by a mattress propped up and held in place by a locked Geri-chair, effectively barricading the residents in bed. When questioned, the nurse assigned to the hallway stated this was done for safety. The investigation determined that the residents were deliberately barricaded in bed, resulting in their confinement without consent. One of the residents later recalled the incident and stated that being confined to bed in this manner felt inappropriate at the time. Staff interviews confirmed awareness of the facility’s abuse policy and protocols for reporting allegations, and staff acknowledged that the incident involved involuntary seclusion of the two residents. The facility’s written policy on abuse, neglect, exploitation, mistreatment, and involuntary seclusion prohibited such practices and required thorough investigation of all allegations, including identification and removal of alleged perpetrators, identification of victims, and documentation of where and when the incident occurred and interview summaries.
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