Other·October 26, 2023

Palomar Heights - 771168 Event ID: T25L11 F- 603- (Free from Involuntary seclusion) The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident (ERI) #: CA00771168 Representing the Department, HFEN #37571 State Citation B was written. Nursing Service- Patient Care - §72315 (b) Each patient shall be treated as an individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. Nursing Service- Restraints and Postural Supports - §72319 (f) Seclusion, which is defined as the placement of a patient alone in a room, shall not be employed. The facility failed to ensure Resident 1 was free from involuntary seclusion (confined to room against her will) when Certified Nursing Assistant (CNA) 1, tied a plastic bag from Resident 1's door to the hallway handrail to prevent Resident 1 from wandering outside the room while undressed. This failure had the potential to result in psychosocial trauma or unwitnessed fall for Resident 1. Findings: Resident 1 was admitted to the facility on 11/18/13, with the diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and repeated falls. Resident 1's brief interview for mental status (BIMS - used regularly to measure and track a resident's cognitive decline) was a 3, which meant, severe cognitive impairment. During an interview on 2/4/22 at 11:15 A.M., with Assistant Director of Nursing (ADON), she stated at approximately 5:15 P.M. on 1/27/22, "...the maintenance manager (MM) came to my office stating there was a plastic bag tied from Resident 1's door to the hallway handrail." ADON immediately went to Resident 1's room, the door was one half open, Resident 1 was walking around her room, ADON performed a head-to-toe assessment on Resident 1. According to the ADON, the CNA said, he tied the door shut because the resident was "undirectable." During an interview on 2/4/22 at 11:20 A.M., the Administrator (Admin.) stated, CNA 1 was terminated on 2/1/22. The Admin. further stated, during his interview on 1/27/22 with CNA 1, the CNA 1 stated Resident 1 repeatedly came out of her room undressed, and undirectable. CNA 1 stated he had to take care of another patient and felt the only way to keep Resident 1 from wandering the hallway undressed was to tie a plastic bag around Resident 1's door handle and then to the handrail. The Admin. stated CNA 1 stated he tied the door closed for less than ten (10) minutes and acknowledged his mistake and failed to call for assistance or report the resident's behavior. During an interview on 2/4/22 at 11:25 A.M., licensed nurse (LN) 1 stated, she usually worked with Resident 1, and there were episodes where Resident 1 would wander in and out of her room and into the corridor undressed, no preference to whether she would remove her top or bottom clothes. LN 1 further stated Resident 1 was ambulatory and unsteady, and needed to hold onto the handrails. LN 1 further stated Resident 1 was redirectable with food or sitting at the nurse's station with staff. During an interview on 2/4/22 at 11:35 A.M., LN 2 stated, Resident 1 "...gets up at times and takes everything off and goes into the hallway. Easily directable." During an interview on 2/4/22 at 11:44 A.M., CNA 3 stated, Resident 1 needed lots of care and wandered around her room and in the hallways with no clothes on. Sometimes Resident 1 would have her pants off, and other times it was her top off, and at times Resident 1 was completely undressed. CNA 3 further stated a way to redirect Resident 1 was to give her food or drink or just sit with her. During an interview on 2/4/22 at 12:18 PM, Maintenance Manager (MM) stated, at approx. 5 PM on 1/27/22, MM went to check on the plastic barrier to the Covid unit. "When I got to the plastic barrier, which is right outside Resident 1's room," he could hear Resident 1 grunting, then MM saw the plastic bag tied to Resident 1's doorknob and the other end to the handrail. MM further stated the plastic bag was only allowing the door to open a little. MM went to get the ADON, and the ADON released the bag completely. During an interview on 2/4/22 at 12:30 PM, the Director of Nursing stated, CNA 1 should not have placed the plastic bag on Resident 1's door, restricting her to her room. During a review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, indicated, "Residents have the right to be free from abuse, neglect...includes but is not limited to freedom from ... involuntary seclusion..." This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a resident. The facility failed to ensure Resident 1 was free from involuntary seclusion when Certified Nursing Assistant (CNA) 1, tied a plastic bag from Resident 1's door to the hallway handrail to prevent Resident 1 from wandering outside the room while undressed. This failure had the potential to result in psychosocial trauma or unwitnessed fall for Resident 1.