Inappropriate Placement of Resident in Secured Unit Without Meeting Criteria or Physician Order
Penalty
Summary
The facility failed to protect a resident from involuntary seclusion when the resident was placed in a secured unit without meeting the unit’s admission criteria and without a physician order. The resident was an elderly female with liver cirrhosis, history of TIA, dementia, schizoaffective disorder, depression, anxiety, and hypertension. Her most recent MDS showed a BIMS score of 4, indicating severely impaired cognition, but documented no hallucinations, delusions, or behavioral symptoms directed toward others. Record review of the order summary for the relevant date showed no order for the resident to be placed in the secured unit. According to staff interviews, the DON directed that the resident be moved to the secured unit late at night due to an episode of shortness of breath, stating that there were more staff available there to monitor her. The usual nurse for the secured unit reported that the resident had been placed there the prior week for closer monitoring after shortness of breath, and that the DON handled the placement. Another LVN stated that the resident had been in her regular room without issues one day and was in the secured unit the next morning, and that she was later directed by the DON to return the resident to her original room. The DON acknowledged that shortness of breath is not a criterion for secured unit placement and that the unit’s criteria require behavioral issues, while the facility’s written secured unit admission criteria require cognitive impairment and assessment of high-risk behaviors such as self-harm or harm to others. The resident did not have documented behavioral issues meeting these criteria.
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