Inaccurate secure-unit placement reviews for two residents
Summary
The facility failed to ensure that two residents were free from involuntary seclusion by not accurately and timely re-evaluating whether their placement in the secure unit remained appropriate. The report states that the facility’s policy required secure unit placement only when specific criteria were met and that placement should end when the condition or behavior justifying it had diminished or the resident no longer met criteria. For both residents, the record lacked documentation from the primary care physician showing that the locked unit was the least restrictive reasonable setting to protect the resident and assure health and safety. Resident #85 had diagnoses including cerebrovascular disease, hypertensive heart disease with heart failure, hypertension, falls, and dementia. The 2/3/26 MDS showed severe cognitive impairment with a BIMS score of 3, total dependence for ADLs, and no physical behavioral symptoms directed toward others. During a continuous observation of the secure unit, the resident sat in the same Broda chair position at the dining table for nearly four hours, was fed by staff, received a magazine, had a hospice nurse visit, was given a doll and a sensory apron, and did not attempt to self-propel or wander. Staff interviews stated the resident was unable to walk or propel herself, never attempted to exit-seek, and could not communicate her needs. The wandering risk assessment documented no wandering in the prior three months and incorrectly stated she could move herself in her wheelchair. Resident #29 had diagnoses including non-Alzheimer’s dementia with behavioral, psychotic, mood, and anxiety disturbances, hypertension, and a history of fractures and TIA. The 1/6/26 MDS showed moderate cognitive impairment with a BIMS score of 9 and dependence on staff for ADLs. The resident told the surveyor she did not like living in the secure unit and did not know the door passcode or why she was there. Observations showed she attended activities outside the secure unit, was returned to the unit, spent time reading in the common area, and later received incontinence care in her room; during the observation she exhibited no wandering, exit-seeking, or aggressive behaviors. The wandering risk evaluation documented no wandering in the prior six months and only occasional following of instructions and redirection, while the nurse practitioner note described her as calm and cooperative. Staff stated she had not been trialed off the unit for three days to evaluate whether transition out of the secure unit was appropriate, and that she had not exhibited exit-seeking behavior.
Penalty
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Two residents were placed in a secured mental health unit without required physician orders or assessments to determine their appropriateness for this level of restriction, resulting in involuntary seclusion. Facility staff confirmed that no orders or assessments were completed for these or thirteen other residents in the unit, contrary to facility policy requiring such evaluations before placement.
A resident with severe cognitive impairment and multiple diagnoses was improperly placed in a secured unit without documented justification. Despite being assessed as low risk for elopement and having no wandering behaviors, the resident was admitted to the secured unit due to a lack of available rooms and the Admissions Coordinator's decision, who lacked medical training. The facility's policy required evaluations for wandering and elopement risks, which were not followed in this case.
A resident was inappropriately placed on a secured memory care unit despite being cognitively intact and competent to make her own decisions. The facility failed to provide sufficient evidence to justify her placement, as there were no documented behaviors such as aggression or wandering. The resident expressed a desire to leave the secured unit, but the facility did not re-evaluate her need for such placement after she was deemed competent.
A resident was placed on a secure unit due to bed availability, despite being a low elopement risk and having intact cognition. The resident was not informed of her ability to leave the unit or given the access code, leading to feelings of confinement. The DON confirmed the placement was due to bed availability and acknowledged the oversight in not providing the resident with the door code or informing her of her right to leave.
A facility failed to ensure a resident met criteria for admission to the secure unit and was in the least restrictive environment. The resident, who was cognitively intact and cooperative, was placed in the secure unit without displaying behaviors warranting such placement and without physician documentation or consent. The facility did not follow its policy requiring a mental and physical assessment and interdisciplinary team documentation.
Failure to Assess and Obtain Orders for Secured Unit Placement Resulting in Involuntary Seclusion
Penalty
Summary
The facility failed to ensure that residents placed in the secured mental health unit (MHU) had appropriate physician orders and assessments to justify their placement, resulting in involuntary seclusion. Specifically, two residents were found residing in the secured MHU without any documented orders or completed assessments to determine their appropriateness for this level of restriction. One resident had severely impaired cognition and was receiving hospice services, while the other was cognitively intact and reported feeling depressed and inappropriately placed in the secured unit. Both residents' records lacked evidence of the required admission process to the MHU. Interviews with facility staff, including the Director of Social Services, DON, and Administrator, confirmed that not only these two residents but also thirteen additional residents in the secured MHU did not have the necessary orders or assessments for their placement. Facility policy required the admissions team to screen and assess residents before placement in the behavioral unit, but this process was not followed. The facility's abuse prevention policy also stated that residents should be free from involuntary seclusion, which was not upheld in these cases.
Improper Admission to Secured Unit
Penalty
Summary
The facility failed to ensure that a resident met the criteria to be admitted to and reside on the secured unit. This deficiency involved a resident who was admitted with multiple diagnoses, including anoxic brain damage, traumatic brain injury, and bipolar disorder, among others. The resident was severely cognitively impaired and required substantial assistance for daily activities. Despite being assessed as low risk for elopement and having no documented behaviors of wandering or exit-seeking, the resident was placed in the secured unit without documented justification. The decision to place the resident in the secured unit was made by the Admissions Coordinator, who lacked medical training and was unaware of specific guidelines for admission to the secured unit. The resident's parent was initially assured that the facility could address the resident's needs and provide therapy and socialization with peers of similar age. However, upon admission, the resident was placed in the secured unit due to a lack of available rooms and the Admissions Coordinator's belief that the resident would receive more attention there due to a seizure disorder. The Medical Director stated that the secured unit was intended for residents who were a threat to leave the facility or had dementia, and that placement should be determined on a case-by-case basis. The facility's policy for the secured unit emphasized providing a safe environment and preventing accidents related to wandering and elopement, with evaluations conducted as part of the preadmission process and upon changes in residents' conditions or functionality.
Inappropriate Secured Unit Placement for Competent Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #103, resided in the least restrictive environment and was free from involuntary seclusion. Resident #103 was placed on a secured memory care unit despite being cognitively intact and competent to make her own decisions. The resident's medical records and progress notes did not provide sufficient evidence to justify her placement on the secured unit, as there were no documented behaviors such as yelling, screaming, verbal aggression, wandering, or medication non-compliance that would necessitate such a restrictive environment. Resident #103 had a history of schizoaffective disorder, bipolar type, and mild dementia with other behavioral disturbances. Despite these diagnoses, the resident was deemed competent and capable of making her own decisions, as confirmed by a statement of expert evaluation. The resident expressed her desire to leave the secured unit and was aware of her rights to make decisions regarding her care. However, the facility did not re-evaluate her need for secured unit placement after she was determined competent, and there was no documentation supporting the necessity of her continued confinement. Interviews with facility staff, including the Administrator and Social Worker Assistant, revealed that Resident #103's placement on the secured unit was initially influenced by her family's request and her past behaviors. However, staff acknowledged that there was no current evidence of behaviors that would justify her placement on the secured unit. The facility's policy required a diagnosis of dementia or other health conditions that would benefit from increased supervision, but Resident #103 did not exhibit behaviors that posed a risk to herself or others, nor did she have a history of elopement or exit-seeking behaviors.
Failure to Ensure Proper Placement on Secure Unit
Penalty
Summary
The facility failed to ensure that residents met the criteria to be admitted to and reside on the secure unit, affecting one resident who was reviewed for involuntary seclusion. The resident, who had diagnoses including neuropathy, muscle weakness, lack of coordination, and anxiety, was admitted to the secure unit due to a lack of available beds elsewhere, despite having intact cognition and being assessed as a low elopement risk. The resident's care plan did not include any information related to the secure unit, and there were no physician orders or documentation justifying the placement on the secure unit. The resident was not informed of her ability to leave the secure unit or given the access code to do so, which was confirmed by both the resident and the Director of Nursing (DON). The DON acknowledged that the resident was placed on the secure unit due to bed availability and was not provided with the door code or informed of her right to leave the unit. This oversight resulted in the resident feeling as though the secure unit was akin to a prison, as she was not made aware of her autonomy to leave the unit at will.
Failure to Ensure Resident Met Criteria for Secure Unit Admission
Penalty
Summary
The facility failed to ensure that a resident met the criteria for admission to the secure unit and was in the least restrictive environment available. The resident, who was cognitively intact with a BIMS score of 13 out of 15, was admitted to the secure unit despite not displaying any behaviors such as hallucinations, delusions, wandering, or exit-seeking that would warrant such placement. The resident was documented as being pleasant, cooperative, and compliant with care and medications, and there was no physician documentation indicating a benefit from residing in the secure unit. Additionally, the resident did not sign a consent to be in the secure unit, and a psychiatric consult conducted later confirmed the resident was alert, oriented, and without any acute psychosis or disturbance of perception. The facility's policy for the secure unit requires a mental and physical assessment documenting that the resident would benefit from such an environment, along with interdisciplinary team documentation that the secure unit is the least restrictive approach. However, the facility did not follow this policy, as there was no initial psychiatric consult or physician documentation supporting the resident's placement in the secure unit. The facility's failure to adhere to its policy and ensure the resident was in the least restrictive environment led to the deficiency identified in the report.
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