This week’s Ftag of the Week on the CMSCG Blog is F603 Free from Involuntary Seclusion, part of the Freedom from Abuse, Neglect and Exploitation regulatory group. Residents have the right to be free from involuntary seclusion, which is when a resident is separated from other residents, from his or her room, or confined to his or her room or in another area against the resident or resident representative’s will. Involuntary seclusion can occur related to secured/locked units if a resident is placed on this unit without meeting the clinical criteria for such placement. There are many circumstances that can constitute involuntary seclusion. Here are some actual deficient practices identified at F603 Free from Involuntary Seclusion:
- A resident pushed her call light and a staff member came into the room, put the call light in the resident’s drawer and closed it, preventing the resident from requesting staff assistance or being able to leave her bed (S/S: D). The Interpretive Guidance (IG) states that residents who are physically placed in an area without access to call lights and/or other methods of communication have been put in a secluded/isolated environment.
- Two residents were prevented from leaving the Activity Room when a staff member physically blocked the door by sitting in a chair with a table next to her to restrict anyone from exiting (S/S: E). The IG states that involuntary seclusion includes attempts to isolate residents to prevent them from leaving an area or involuntarily confines them in an area by staff placing carts or furniture in front of means of egress/doorways.
As you can see from these examples, staff in these scenarios each took action to restrict or isolate residents rather than implementing individualized interventions for each resident. Staff need to understand their responsibilities regarding following the resident’s individual plan of care and how they can create a situation of involuntary seclusion if they don’t understand acceptable standards of practice. Surveyors are instructed to observe whether staff make remarks or behave in a way that indicates there are issues with the way staff are treating residents. Everyone needs to be familiar with be familiar with the Abuse, Neglect and Exploitation regulatory group.
Transmission-Based Precautions and Involuntary Seclusion
In some cases, isolating a resident cannot be prevented, and if transmission-based precautions are warranted and used appropriately, this will not be considered involuntary seclusion. Per the IG, the resident’s medical record must include the rationale for the selected precautions, and facilities must have in place policies that:
- Identify the type and duration of required transmission-based precautions
- Ensure the precautions put in place are the least restrictive for the resident based on the clinical situation
It is important to ensure thorough communication when residents have been isolated in these situations. A facility was cited for not knowing that a resident’s antibiotic therapy had ended two months prior to a surveyor inquiry after the resident was interviewed and said she was only out of her room for treatments and appointments and could not attend activities she liked. Staff were not aware as to why the resident had been isolated for so long. Precautions must be the least restrictive, and the plan of care should include interventions to ensure the resident can still participate in room-based activities that are of interest to him/her.
Secured/Locked Units and Involuntary Seclusion
The IG at F603 provides criteria for ensuring that a resident in a secured or locked unit is not considered to be involuntarily secluded. These include:
- Identifying the clinical criteria for placing the resident in a secured or locked area. Many facilities have been cited during survey for having residents reside on secured units or dementia units who do not have appropriate clinical indications that this type of restrictive environment is needed. For instance, a facility was cited for having a cognitively intact resident reside on a secured unit. The resident told surveyors that he often has to go to appointments outside the facility and needs to wait for staff to let him come in and out of the unit. The resident’s clinical record did not include any documentation that the resident needed to reside on a secured unit.
- Using a resident’s diagnosis as the sole basis for determining placement. Determination for placement in a secured area must be made on an individualized basis to ensure the safety of the resident. Residents, particularly those living with dementia, should be allowed to reside in the least restrictive environment possible, while ensuring they remain safe.
- Ensuring that placement is not based on request from a resident representative/ family member when there is no clinical justification. In one citation reviewed at F603, a resident was found to be the only resident living in a secured unit. Interviews and record review found that the resident did not meet the clinical criteria for placement and that she was only on the unit due to the family’s preference.
- Ensuring that placement is not for staff convenience or disciplinary purposes. A facility was cited for placing multiple residents living with dementia on a secured unit when they did not meet the clinical criteria for placement in a secured unit. This was put in place due to staffing issues since the facility had issues with turnover for positions that required 1:1 supervision. There was also a lack of appropriate programming in place for the residents on other units, so they were taken to the secured unit.
Do not forget that if a resident experiences an escalation in behavior and requires immediate interventions to ensure the safety of the resident and/or others, that the staff must consult with the resident’s physician regarding the behavioral symptoms. The resident’s representative should also be contacted. Any necessary supervision required to protect the resident or others should be put into place, but isolating the resident in a manner such as placing the resident in an area secluded from staff or other residents as punishment or to avoid having to deal with the resident is considered involuntary seclusion. Residents who exhibit behavioral symptoms should have strong, individualized care plans in place with nonpharmacological interventions that staff can attempt for de-escalation purposes. In many of the citations reviewed for F603, staff did not appear to have a good understanding of the residents’ needs or how to assist them with feeling better. Remember, your staff should be provided with the necessary information and tools, including training and education, to help them prevent abuse, neglect and mistreatment in the workplace while ensuring residents do not have negative outcomes.
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