Resident Kept at Nurse’s Station Overnight Against Wishes to Avoid Fall Reports
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from involuntary seclusion by keeping the resident up in a wheelchair at the nurse’s station for most of the night against the resident’s expressed wishes. The resident was admitted in 2025 with diagnoses including a hip fracture and dementia, and the care plan dated 12/2025 did not include any intervention to keep the resident at the nurse’s station all night to prevent falls. Despite this, on at least one night, the resident was kept at the nurse’s station until approximately 2:00–2:30 AM, provided incontinence care, and then returned to the nurse’s station and kept there until 5:00 AM, even though the resident requested to go to bed and did not usually stay up at night. Multiple staff interviews described that an LPN insisted on keeping the resident up at the nurse’s station because the resident had a history of falls and the LPN did not want to complete additional incident reports. CNAs reported that when they attempted to put the resident to bed after incontinence care, the LPN intervened and directed them to get the resident back up, despite the resident stating a desire to remain in bed. Staff observed the resident’s coffee cup being repeatedly refilled at night, which they stated was not normal for this resident, and the resident was positioned at the nurse’s station with a table, coffee, and magazines while being kept awake. Other nursing staff reported that on more than one night the LPN attempted to keep the resident up at the nurse’s station, tucking a blanket around the resident in the wheelchair and leaning the chair back while the resident stated being tired and wanting to go to bed. Staff stated they informed the LPN that forcing the resident to remain in the chair at the nurse’s station instead of allowing the resident to go to bed was abusive. The LPN acknowledged keeping the resident up at the nurse’s station due to concerns about falls and incident reports, and facility leadership confirmed that residents could be monitored at the nurse’s station but not for the entire night and not for staff convenience. This conduct resulted in the resident being subjected to involuntary seclusion and not being allowed to go to bed when requested.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.