Resident Involuntarily Secluded by Medication Cart Blocking Room Exit
Penalty
Summary
Facility staff failed to protect a resident from involuntary seclusion when a medication cart was used to block the resident’s room exit. The resident had been admitted with Alzheimer’s disease and dementia and had a Minimum Data Set (MDS) assessment indicating severe cognitive impairment (BIMS coded 99) and daily wandering behaviors. A facility-reported incident documented that Registered Nurse Staff A placed a medication cart in front of the resident’s doorway, preventing the resident from leaving the room. A progress note by the Director of Nursing Services (DNS) recorded that the resident was found with the medication cart blocking the doorway. Further review of a statement from the DNS showed that Staff A admitted she positioned the cart to prevent the resident from roaming the facility while the resident had COVID-19. During an interview, the Maintenance Director reported that when he attempted to remove the cart, he observed a cord attached to the cart, with the other end wrapped several times around a wall-mounted glove box outside the door, securing the cart in place. In a surveyor interview, the DNS acknowledged that while assisting the Maintenance Director to remove the cart, it was determined that the cart had been tied in place, blocking the resident’s ability to leave the room.
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