F0580

D

Failure to Notify Physician of Behavioral Change and Inappropriate Use of Medication Room for Observation

New Britain, Connecticut Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify the physician of a significant change in a resident’s behavior and the subsequent placement of the resident in a medication room with the door closed for an extended period. The resident had diagnoses including dementia, insomnia, end stage renal disease, failure to thrive, and depression, and was identified as moderately cognitively impaired, dependent for all care, and wheelchair bound. The resident’s care plan directed staff to assess mood every shift and obtain psychiatric services if mood declined. In the days leading up to the incident, nurse’s notes documented that the resident often yelled out continuously and was sometimes calmed when brought near the nurse’s station. An FNP note indicated recent falls, increased confusion, anxiety, and a discussion with family about starting Trazodone, which the family declined.

On the date of the incident, staff reported that the resident was anxious, trying to get out of bed, and screaming throughout the shift, with usual redirection attempts unsuccessful. NA #1 brought the resident to the nurse’s station due to restlessness and high fall risk. RN #2, the nursing supervisor, determined the resident should be kept under direct observation and attempted to position the resident behind the nurse’s station, but the custom wheelchair would not fit. RN #2 then placed the resident in the medication room located directly behind the nurse’s station and shut the door. Written statements and interviews indicated that the resident remained in the medication room in the wheelchair with the door shut for approximately one and one-half hours, and that staff referred to this as “solitary confinement.”

Review of the clinical record and nurse’s notes for the 24 hours preceding the incident showed no documentation that the physician was notified of the resident’s increased agitation and behavioral escalation, despite the facility’s dementia care policy directing appropriate referrals to the physician or mental health provider when current interventions were ineffective or when there was a decline in psychosocial, mood, or behavioral status. Interviews confirmed that staff were unable to de-escalate the resident’s behaviors and that the family member was not contacted for assistance until early the following morning. The facility documentation and staff interviews collectively demonstrated that the resident’s significant change in behavior was not reported to the physician and that the resident was instead placed in the medication room with the door closed for close observation.