Failure to Timely Report Allegation of Involuntary Seclusion
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of involuntary seclusion involving one resident. The resident had dementia, insomnia, end stage renal disease, failure to thrive, depression, was moderately cognitively impaired with a BIMS score of 9, unable to make reasonable and consistent decisions, dependent for all care, and wheelchair bound. The resident’s care plan called for assessment every shift, medication administration as ordered, encouragement to participate in care, and psychiatric services and emotional support if mood declined or the resident self-isolated. On the evening in question, the resident was reportedly screaming, anxious, trying to get out of bed, and attempting to climb out of bed. Multiple staff members, including nursing assistants and nurses, observed that the resident was placed in the medication room with the door shut for close observation and to prevent disruption to other residents. Staff accounts documented that an RN directed that the resident be brought to the nurse’s station and then placed the resident in the medication room with the door shut, referring to the situation as a way to watch the resident and allow others to sleep. Other staff, including an NA and LPNs, noted they had never seen a resident placed in the medication room in this manner, questioned the appropriateness of the action, and one LPN described it as “solitary confinement.” Despite having received abuse and neglect training and being aware that involuntary seclusion is a form of abuse, these staff did not report the incident as suspected abuse at the time it occurred, citing reasons such as not realizing it was wrong or believing the resident was not their patient. The DON later learned of the incident only when speaking with staff about interactions with the RN involved, at which point the facility initiated an investigation and completed a Reportable Event Form several days after the incident, contrary to the facility’s abuse policy requiring suspected abuse to be reported to the Administrator immediately and no longer than two hours after an allegation is made.
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