Failure to Protect Resident From Involuntary Seclusion and Unconsented Transfer to Secured Unit
Penalty
Summary
The facility failed to protect a resident’s right to be free from involuntary seclusion when a cognitively intact resident was moved to a secured memory care unit and restricted in his room without clear consent or appropriate capacity determination. The resident, who had a BIMS score of 15 indicating intact cognition, reported that he had been moved "back here against my will" and that his door had been taped with a sign stating "do not enter," leaving him locked in his room for three days. Although the clinical record contained Power of Attorney paperwork authorizing his children to make health care decisions if he could not decide for himself, the record lacked a physician’s incapacity statement indicating that he was unable to make his own decisions. The Director of Regional Operations stated that the resident was moved to the secured memory care unit for the safety of female residents due to his inappropriate statements and behaviors, and asserted that the resident had confusion but made the decision himself, referencing progress notes but acknowledging there was nothing signed by the resident agreeing to the move. She also confirmed there was no physician statement of lack of capacity. A stop sign was placed across the resident’s door as an intervention to prevent others from entering his room. A psychology progress note documented that the resident made self-harm statements related to distress about being moved to a different room and that he linked these statements directly to his upset about the room change, stating he would not make such statements if moved back to his previous room. Social services confirmed that the resident had contacted the VA suicide hotline, denied intent to harm himself when interviewed, and that psychiatry had been notified. A Regional Nurse reported that an audit of advance directives and incapacity statements had been completed but did not determine whether residents actually needed incapacity statements.
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