Failure to Allow Independent Egress for Residents Not at Elopement Risk
Summary
The facility failed to ensure that residents who did not meet clinical criteria for residing on a locked unit were provided with a method to independently open secured doors. Observations across multiple days revealed that both nursing units had locked doors requiring a keypad code for entry and exit, and only staff were observed inputting the code for residents and visitors. Signage instructed individuals to call a phone number if staff were unavailable, and knocking on the door or window was discouraged. Review of facility records showed that a significant number of residents on both units were not at risk for elopement, yet were still subject to the same locked-door restrictions as those who were at risk. Interviews with staff and leadership confirmed that all residents, including those who were independent and cognitively intact, were not allowed to leave the units without staff accompaniment. The facility was unable to provide risk assessments or criteria for placement on secured units, and there was no policy available regarding secured/locked units or assessment for such placement. Additionally, the Director of Nursing Services acknowledged that there was no strategy in place to secure only those residents identified as elopement risks, resulting in all residents being restricted regardless of their assessed risk. An incident was observed where a resident was unable to enter their unit after exiting the elevator because they did not have the keypad code, leading to visible distress. Staff interviews indicated that residents on one unit were given the code, while those on the other were not, and there was no clear process for ensuring door security or tracking which residents were permitted to leave. The facility's elopement and wandering policy referenced the use of locks and alarms for residents at risk, but did not address the needs or rights of residents not at risk for elopement.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with moderate cognitive impairment and multiple chronic conditions repeatedly called 911 at night due to perceived hallway noise. In response, an LVN and a CNA entered the room; the CNA held the resident’s arms down while the LVN removed the resident’s personal cell phone from his clothing and took it to the nurse’s station without consent. The resident’s wheelchair was also removed from the room to the hallway, and staff refused his requests to be assisted out of bed into the wheelchair, telling him to remain in bed. These actions, confirmed in staff interviews and contrary to the facility’s abuse prevention policy, resulted in the use of physical restraint, unreasonable confinement, and deprivation of the resident’s personal property and services.
A resident with dementia and multiple comorbidities, but no documented psychosis or behavioral symptoms, was moved from her regular room to a secured unit for closer monitoring after an episode of shortness of breath, without a physician order and despite not meeting the facility’s written secured unit admission criteria. Staff, including LVNs and the DON, reported that the move was made at night for observation because more staff were present in the secured unit, and the resident was returned to her original room the following morning. The DON acknowledged that shortness of breath is not a criterion for secured unit placement and that the unit is intended for residents with behavioral issues, while the facility’s criteria require cognitive impairment plus assessment of high-risk behaviors such as self-harm or harm to others, which were not documented for this resident.
A resident with Alzheimer’s disease, dementia, severe cognitive impairment (BIMS 99), and daily wandering behaviors was involuntarily secluded when an RN placed a medication cart in front of the resident’s doorway to prevent roaming while the resident had COVID-19. The DON documented that the cart blocked the room exit, and later interviews revealed the cart had been secured in place with a cord wrapped around a wall-mounted glove box, fully obstructing the resident’s ability to leave the room.
A resident with dementia, multiple comorbidities, and total dependence for care, who frequently yelled out and was sometimes calmed when near the nurse’s station, was placed in the medication room with the door closed for about one and one-half hours due to agitation, yelling, and attempts to get out of bed. A CNA brought the resident to the nurse’s station for anxiety and restlessness, and the supervising RN, unable to fit the wheelchair behind the nurse’s station, directed that the resident be placed in the medication room and shut the door so other residents could sleep, stating it was easier to watch the resident there. Staff later described the situation as “solitary confinement,” confirmed the door was shut though unlocked, and documented that the resident remained there until after midnight before being returned to their room. This conduct conflicted with the facility’s abuse policy, which prohibits involuntary seclusion defined as separating a resident from others or from their room against the will of the resident or representative.
A resident with dementia and a history of falls was repeatedly kept up in a wheelchair at the nurse’s station for most of the night by an LPN, despite the resident’s stated desire to go to bed and the absence of any care-plan directive to keep the resident up all night. CNAs reported that when they attempted to put the resident to bed after incontinence care, the LPN ordered them to get the resident back up, refilled the resident’s coffee, and positioned the resident with a blanket, coffee, and magazines at the nurse’s station, stating she did not want to complete more incident reports for falls. Other nursing staff told the LPN this was abusive, and leadership later confirmed that keeping a resident at the nurse’s station all night for staff convenience was not acceptable, constituting involuntary seclusion.
A resident with profound intellectual disability, severe cognitive impairment, and total dependence on staff for mobility was found by a surveyor alone in a vacant room bathroom, in a wheelchair facing the wall, repeatedly stating she was cold and asking to be removed, in a room later measured at about 60°F. Earlier that evening, a CNA had discovered the resident in the same vacant bathroom, moved her to the common area for supper, and then, per his account, returned her to the bathroom at the direction of an LPN, positioning her wheelchair sideways by the door. The resident, who could not self-propel due to bilateral hand contractures and required extensive assistance for all transfers and locomotion, remained separated from other residents for several hours until the surveyor’s discovery. Staff interviews confirmed the resident normally stayed in the common area, could not move herself, and that leaving a resident in a bathroom without consent would constitute involuntary seclusion under the facility’s abuse/neglect policy, leading to an Immediate Jeopardy finding for involuntary seclusion.
Abusive Use of Physical Restraint and Removal of Resident Property During 911 Call Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse, including physical restraint, unreasonable confinement, and deprivation of property and services. The resident was an adult male with a history of vitamin deficiency, pain, hypertensive heart disease, type 2 diabetes, and muscle weakness. His quarterly MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and his care plan identified potential risk for impaired cognitive function or thought processes related to psychotropic drug use, history of stroke, and mild cognitive impairment. His care plan interventions included using his preferred name, identifying oneself at each interaction, reducing distractions, using simple directive sentences, and providing cues, reorientation, and supervision as needed. On the night of the incident, the resident repeatedly called 911 from his room due to noise in the hallway that he felt was preventing him from sleeping. According to interviews and the facility’s investigation, he placed approximately 14 calls to 911 within about 10 minutes. Law enforcement contacted the facility and requested staff intervention. In response, staff members identified as an LVN and a CNA went to the resident’s room. During this encounter, the resident reported that one staff member held his arms down while the other removed his personal cell phone from the front of his clothing and took it to the nurse’s station, telling him it would be returned in the morning. The resident stated that he felt physically restricted during this interaction and that staff took his cell phone without his consent. The resident further reported that his wheelchair was removed from his room and placed in the hallway. He stated that he requested assistance to be transferred into his wheelchair and to leave the room, but staff refused his request, instructing him to remain in bed because it was late. He indicated that he could not get up independently and required two-person assistance. Interviews with the DON, LVN, and CNA confirmed that the CNA held the resident’s hands while the LVN removed the phone, and that holding the resident down was recognized as a form of physical restraint. The removal of the resident’s wheelchair from his room and the refusal to assist him out of bed restricted his movement. The facility’s abuse prevention policy defined abuse to include willful infliction of injury, unreasonable confinement, and deprivation of goods or services necessary to maintain physical, mental, and psychosocial well-being, and staff acknowledged that holding a resident down and removing personal property such as a phone without consent met this definition.
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.
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.
Involuntary Seclusion of a Cognitively Impaired Resident in Medication Room
Penalty
Summary
The deficiency involves the involuntary seclusion of a resident with dementia and multiple comorbidities who was placed in the facility’s medication room with the door closed for approximately one and one-half hours due to agitated behaviors and continuous yelling. The resident had diagnoses including dementia, insomnia, end-stage renal disease, failure to thrive, and depression, and was assessed as moderately cognitively impaired, unable to make reasonable and consistent decisions, dependent for all care, and wheelchair bound. The resident’s care plan addressed self-care deficits and mood concerns but did not include interventions involving separation from other residents or placement in a medication room. In the days leading up to the incident, nursing notes documented that the resident frequently yelled out continuously throughout shifts, with some decrease in yelling when brought near the nurse’s station. On the day of the incident, staff reported the resident was anxious, trying to get out of bed, and screaming throughout the shift. A nursing assistant brought the resident to the nurse’s station, and the supervising RN directed that the resident be brought there for closer observation. When the resident’s wheelchair could not be accommodated behind the nurse’s station, the supervising RN placed the resident in the medication room and shut the door, stating it was easier to watch the resident there and to allow other residents to sleep. Written statements and interviews confirmed that the resident remained in the medication room with the door shut, with staff referring to the situation as “solitary confinement” and acknowledging the resident had been yelling all evening. The medication room door was unlocked and had clear glass panels, allowing visual observation, and at some point after midnight, vital signs were obtained and the resident was returned to their room, where they slept for the remainder of the night. The facility’s abuse policy stated that residents would be protected from involuntary seclusion, defined as separation from other residents or the resident’s room against the will of the resident or the resident’s representative. The placement of the resident in the medication room with the door closed for behavioral reasons constituted the separation that led to the cited deficiency.
Resident Kept at Nurse’s Station Overnight Against Wishes to Avoid Fall Reports
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from involuntary seclusion by keeping the resident up in a wheelchair at the nurse’s station for most of the night against the resident’s expressed wishes. The resident was admitted in 2025 with diagnoses including a hip fracture and dementia, and the care plan dated 12/2025 did not include any intervention to keep the resident at the nurse’s station all night to prevent falls. Despite this, on at least one night, the resident was kept at the nurse’s station until approximately 2:00–2:30 AM, provided incontinence care, and then returned to the nurse’s station and kept there until 5:00 AM, even though the resident requested to go to bed and did not usually stay up at night. Multiple staff interviews described that an LPN insisted on keeping the resident up at the nurse’s station because the resident had a history of falls and the LPN did not want to complete additional incident reports. CNAs reported that when they attempted to put the resident to bed after incontinence care, the LPN intervened and directed them to get the resident back up, despite the resident stating a desire to remain in bed. Staff observed the resident’s coffee cup being repeatedly refilled at night, which they stated was not normal for this resident, and the resident was positioned at the nurse’s station with a table, coffee, and magazines while being kept awake. Other nursing staff reported that on more than one night the LPN attempted to keep the resident up at the nurse’s station, tucking a blanket around the resident in the wheelchair and leaning the chair back while the resident stated being tired and wanting to go to bed. Staff stated they informed the LPN that forcing the resident to remain in the chair at the nurse’s station instead of allowing the resident to go to bed was abusive. The LPN acknowledged keeping the resident up at the nurse’s station due to concerns about falls and incident reports, and facility leadership confirmed that residents could be monitored at the nurse’s station but not for the entire night and not for staff convenience. This conduct resulted in the resident being subjected to involuntary seclusion and not being allowed to go to bed when requested.
Involuntary Seclusion of Dependent Resident in Vacant Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from involuntary seclusion when the resident was placed and left in a vacant bathroom for an extended period. The resident was an adult female with profound intellectual disability, severe cognitive impairment, poor short- and long-term memory, severely impaired decision-making, significant behavioral symptoms (including loud vocalizations), and extensive physical limitations including bilateral upper and lower extremity impairment, bilateral hand contractures, and dependence on staff for all mobility and transfers. Her care plan documented that she was dependent on staff for wheelchair locomotion, did not sleep in bed by preference, and required extensive assistance from two staff for transfers. She was known to prefer remaining in her wheelchair in the common area and to be unable to self-propel due to her contracted hands. On the evening of the incident, staff reported that the resident was normally in the common area around supper time and that she typically sat and often slept in her wheelchair in that area. CNA A stated that around the supper hour he went to deliver the resident’s meal tray and noticed she was not in the common area or her room. He reported hearing her characteristic sounds from the end of the hall, finding her in the bathroom of a vacant room, and then assisting her out of that bathroom and back to the common area for supper. CNA A stated he informed LVN B that he had found the resident in the vacant room bathroom. According to CNA A, after the resident was brought back to the common area and was eating, LVN B “threw up her hands” and instructed him to take the resident back to where he had found her. CNA A reported that he then returned the resident to the vacant room bathroom and positioned her wheelchair sideways by the door, facing the wall. Later that night, at approximately 10:55 p.m., the surveyor walking down the hall heard strange noises and found the resident alone in the bathroom of the vacant room. The resident was in her wheelchair facing the wall, making loud moaning/chanting sounds, repeatedly stating she was cold and asking to be taken out, tearful, and shaking. She was wearing a dirty clothing protector covered with food. The room and bathroom were described as cold, and a subsequent temperature check of the vacant room showed 60.2°F. The resident was known to be totally dependent on staff for mobility and transfers and unable to self-propel her wheelchair. CNA C, who was assigned to the resident that shift, stated she was unaware the resident had been placed in the vacant room bathroom and confirmed the resident could not propel herself. Multiple staff, including the DON and ADON, later acknowledged that leaving a resident in a bathroom without permission and away from others would constitute involuntary seclusion. The facility’s own abuse/neglect policy defined involuntary seclusion as separation of a resident from other residents or from his/her room, or confinement to his/her room, against the resident’s will or that of the legal representative. These circumstances led surveyors to identify an Immediate Jeopardy related to involuntary seclusion for this resident. Additional interviews with staff on both day and night shifts established that the resident was routinely dependent on staff for all movement in her wheelchair and that she was typically observed in the common area, not in vacant rooms. Staff consistently reported that the resident did not prefer to be in bed and often slept in her wheelchair in the common area, but none reported any prior practice of placing her alone in a vacant room or bathroom. Several staff, including CNAs and LVNs, stated they had been in-serviced on abuse, neglect, and resident rights, and that they were expected to report any suspected abuse or neglect to the Administrator, who served as the abuse coordinator. CNA A later acknowledged that returning the resident to the bathroom at the direction of LVN B was isolating the resident and against her rights, and that he should have contacted the Administrator instead of complying with the directive. The DON and ADON both stated that leaving a resident in a bathroom without consent would be considered seclusion, and the Administrator characterized the incident as involuntary seclusion with potential for emotional impact on the resident. The surveyor’s observations and staff interviews documented that the resident remained in the vacant bathroom, in a room with a temperature of about 60°F, for a prolonged period estimated at approximately five hours before being discovered by the surveyor. During this time, the resident, who was unable to move herself, was separated from other residents and from her usual environment in the common area. LVN B reported that she last saw the resident in the common area around supper time and did not see her again until the surveyor found her later that night. She stated she had instructed CNA A to assist the resident to get a shower but did not verify that this occurred and reported being occupied with blood sugar checks and blood pressures on the hall. Other staff on duty, including CNAs and LVNs on the 200 hall, stated they were unaware that the resident had been placed in a vacant room bathroom and did not recall seeing her during the time she was secluded. These combined actions and inactions resulted in the resident being involuntarily secluded in a cold, vacant bathroom for several hours, leading to the Immediate Jeopardy finding under F603 (Free from Involuntary Seclusion).
Removal Plan
- Resident #1 was removed from room [ROOM NUMBER] by the Licensed Nurse (LVN B).
- Resident #1 was assisted to the shower room via wheelchair and soiled clothing changed.
- Blankets were placed around Resident #1.
- Resident #1 was assessed by the Licensed Nurse (LVN B) related to abuse and neglect and psychosocial status with no concerns noted.
- An allegation of potential seclusion was reported to HHSC as well as Law Enforcement for Resident #1 by the Facility Administrator.
- An investigation into the incident was immediately initiated by the Facility Administrator, including interviews with facility staff on duty.
- The Licensed Nurse (LVN B) and the two Certified Nursing Assistants (CNA A and CNA C) assigned to 100 hall on the 6 pm-6 am shift were suspended pending investigation outcome by the Facility Administrator.
- The Administrator and/or designee conducted facility rounds in all rooms to observe for the presence of abuse and/or neglect, to include potential seclusion, with no concerns noted (ensuring residents were present in assigned rooms/beds; observing for residents unattended in bathrooms and/or resident areas; and/or visibly noted or reporting symptoms of distress), documented on a resident room roster and facility map.
- The Administrator and/or designee interviewed interviewable residents related to abuse and neglect, to include involuntary seclusion, with no concerns noted, documented on a questionnaire for each resident.
- The Director of Nursing and/or designee assessed residents with a BIMS score below 13 head-to-toe related to abuse and neglect and psychosocial status, with no concerns noted, documented in the resident's progress note.
- The Director of Nursing and/or designee reviewed resident progress notes for the last 30 days to ensure concerns related to abuse and neglect, to include potential seclusion, were identified; no additional concerns were identified; review was documented using printed progress notes for each current resident.
- The Administrator and/or designee completed temperature checks in all resident rooms and resident use areas; all temperatures were within 71-81 degrees Fahrenheit; findings were documented on an audit tool and will continue daily Monday to Friday.
- Any facility staff on FMLA, Leave of Absence, non-scheduled workday, or PTO will be reeducated by the Administrator and/or designee and/or Director of Nursing and/or designee on all reeducation detailed below prior to the start of their next scheduled shift.
- The Regional [NAME] President of Operations reeducated the Facility Administrator (Abuse Coordinator) and Director of Nursing on the facility's abuse and neglect policy and procedure to include involuntary seclusion (including examples of actions that would meet the criteria for involuntary seclusion).
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