Failure to Prevent Involuntary Seclusion Due to Improper Secure Unit Placement
Summary
The facility failed to ensure that a resident was free from involuntary seclusion and physical restraint not required to treat medical symptoms. A female resident with severe cognitive impairment, dementia, and heart failure was admitted and later placed on a secure unit. Documentation showed that initial elopement risk assessments indicated no risk, and there was no evidence of behavioral symptoms such as wandering or exit-seeking prior to her transfer. The resident's care plan and medical record did not contain orders or clear documentation justifying her placement on the secure unit at the time of transfer. Interviews with staff, including CNAs and LPNs, revealed that the resident had not exhibited exit-seeking behaviors or attempts to elope. Staff described her as forgetful and easily redirected, with occasional wandering only when searching for misplaced items. The resident herself did not express distress about her placement and participated in activities, but her family was not informed about the reason for her move to the secure unit and requested her return to the general population. The care plan was updated to reflect elopement risk only after the investigation began, and the elopement risk evaluation with a moderate risk score was not completed or available in the electronic medical record until after the surveyor's inquiry. Facility leadership, including the ADON and DON, could not provide consistent or documented reasons for the resident's placement on the secure unit, and there was no physician order for the move. The facility's policy on wandering and elopement did not specify criteria or procedures for secure unit placement. The lack of proper assessment, documentation, and communication regarding the resident's transfer to the secure unit constituted a failure to protect the resident from involuntary seclusion.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Involuntary Seclusion on Secured Unit: A resident admitted with respiratory failure and bipolar disorder was documented as cognitively intact and later as alert and responsive, yet after attempting to leave the unit she fell near the secured doors and stated staff would not let her leave. Two other residents with BIMS scores of 15 and low elopement risk also reported they were not given the door code and had to ask staff to let them out, while staff said there was no written list of who could leave independently.
A resident with anxiety disorder and vascular dementia was repeatedly yelling that she needed to use the toilet, but staff told her to wait during shift change. Video showed a CNA taking her to her room, shutting the door, and leaving her there while staff remained at the nurses' station. Staff later stated the resident was moved to her room because her yelling was disruptive and toileting was delayed until another CNA was available.
Failure to assess and notify the physician after moving a resident to the secured memory care unit. A resident with depression, anxiety, epilepsy, and cognitive impairment was transferred from the skilled unit after staff reported going to the front doors, but the record had no documentation of a room change, exit-seeking behavior, or completed assessments. The RDON confirmed no assessment was done and the physician was not contacted, while the resident’s sister/POA said she was unaware of the move and of any dementia dx.
Involuntary Seclusion by Tying a Resident’s Door Shut. A resident with bipolar disorder, violent behavior, and moderate cognitive impairment became physically aggressive toward staff and a roommate, and staff then tied a sheet from the resident’s room door handle to a hallway handrail so the resident could not leave the room. Staff interviews and nursing notes described the resident as alone in the room, calling for help, and being kept in place by the tied sheet, which the DON and ADON acknowledged as involuntary seclusion.
A resident with anxiety, bipolar disorder, and major depressive disorder, who was cognitively aware, non‑ambulatory, and dependent for ADLs, was removed from his room by a CNA while yelling out, pushed in a geriatric chair into a shower room, and left there alone with the door locked for approximately 30 minutes to an hour without receiving a shower and without his consent. The resident reported telling the CNA he did not want to go into or be left in the shower room and later expressed anger about being confined there against his will. An LPN and another CNA found the resident locked in the shower room, observed him in a reclined geriatric chair asking to be let out, and noted he had a pink face and difficulty breathing. The CNA admitted he placed the resident in the shower room and left him unattended so the resident would quiet down and not disturb others, and the Administrator acknowledged that this confinement met the facility’s definition of seclusion and abuse.
Locked exit doors prevented residents from freely leaving the facility without individualized assessment, clinical justification, or care planning. Surveyors found that multiple residents were cognitively intact or only mildly impaired, independent with mobility, and documented as not being at risk for elopement, yet all doors were locked and only staff had the codes. The administrator confirmed residents could not independently exit and that no waivers or individualized assessments had been completed to support the restriction.
Involuntary Seclusion on Secured Unit
Penalty
Summary
The facility failed to prevent involuntary seclusion for three residents by not consistently allowing them independent access to leave a secured unit. The report defines 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. During the survey, the Nursing Home Administrator stated there was no policy for determining who gets the code to the door on 2 West, and staff interviews showed there was no written list of residents permitted to have the door code. One resident was admitted with respiratory failure with hypoxia and bipolar disorder and was documented on arrival as cognitively intact, oriented to person, place, and time, and later as alert and responsive and able to make needs known. After a fall near the unit's secured doors, an APN documented that the resident had been attempting to elope from the facility and was trying to get out the door when she fell backward and hit her head. The resident also stated that a nurse would not let her leave the unit. The DON stated that residents who are alert and oriented get the code to the doors unless they are considered an elopement risk, but also stated that the resident had been in the facility less than 24 hours and no elopement evaluation was done before the fall. Two other residents were also found to be denied independent access despite being assessed as low elopement risk and having BIMS scores of 15. One resident stated that he/she had never been given the door code and had to get staff to let him/her out for activities. Another resident stated that he/she did not have the code to the unit door and had to ask staff to let him/her out if he/she wanted to leave the unit. Staff interviews confirmed that residents on the unit usually did not have the code, that there was no list of who was allowed to leave independently, and that on weekends agency staff would not know who could leave, so residents were not allowed off the unit until they were assessed.
Resident confined to room during toileting delay
Penalty
Summary
The facility failed to ensure a resident with anxiety disorder and vascular dementia with behavioral disturbance was not isolated in her room. The resident was observed and heard repeatedly yelling in the hallway that she needed to use the bathroom and would soil herself if she did not go. Staff told her she would have to wait because other residents were being brought back from the dining room, and the resident continued yelling during the shift change period. Video footage showed the resident sitting near the nurses' station, then being taken into her room by a CNA. The CNA exited the room, shut the door, and returned to sit behind the nurses' station while the resident remained in the room. The resident was not seen with staff in the room until another CNA entered later, followed by the first CNA. The footage also showed staff talking at the nurses' station, checking residents for shift change, and delaying toileting while the resident continued to vocalize her need to use the bathroom. Staff statements indicated the resident had been yelling about needing to toilet and that the room placement was done because her yelling was disruptive during shift change. One CNA stated she took the resident to her room to avoid disturbing other residents and planned to toilet her when another CNA became available. Another staff member stated the resident had been told she would be toileted soon because it was shift change. The report cited this as unreasonable confinement and separation of the resident from other residents or confinement to her room.
Failure to Assess and Notify Physician After Move to Secured Memory Care Unit
Penalty
Summary
The facility failed to ensure proper assessment and physician notification after moving Resident #59 to the secured memory care unit. Resident #59 was admitted with diagnoses including depression, anxiety, and epilepsy, and the admission MDS showed cognitive impairment with assistance needs for several activities of daily living. The care plan later documented that the resident resided on the secured memory care unit for a therapeutic environment related to dementia and had exit-seeking behavior, with interventions to encourage the resident to avoid secured doorways and to periodically reevaluate the need for the secured unit. However, the medical record contained no documentation of a room change or exit-seeking behavior in the progress notes, and the admission evaluation stated the resident had a history of wandering but did not have exit-seeking behavior and had not attempted to elope from the unit or facility. The record showed a census change from the skilled unit to the secured memory care unit, but no further documentation or assessments were noted about the move. An elopement evaluation also stated the resident did not wander within the facility, had no history of wandering, and had no exit-seeking behavior or actual elopement attempts. The resident’s sister and POA stated she was surprised by the move to the secured memory care unit and was unaware of a dementia diagnosis, and the RDON confirmed the resident was moved after staff observed going to the front doors, but no assessments were completed and the physician was not contacted.
Involuntary Seclusion by Tying Resident Room Door Shut
Penalty
Summary
The facility failed to ensure that a resident was kept free from involuntary seclusion when staff tethered a bedsheet from the resident’s room door handle to a hallway handrail, which physically prevented the resident from leaving the room. The resident involved, R1, was documented as a female with diagnoses including polyneuropathy, bipolar disorder with severe manic episode, unspecified protein-calorie malnutrition, and violent behavior. Her MDS documented a BIMS score of 8, indicating moderate cognitive impairment. On 5.2.2026, nursing documentation stated that R1 was physically aggressive toward her roommate and staff, attempted to hurt her roommate, came to the nurse’s station, grabbed the pill crusher machine, and bit a nurse on the right arm. Staff interviews described that R1 was moved back to her room and then a sheet was placed on the door and tied to the hallway handrail so she would not get out. One CNA stated the door was completely closed, R1 was alone in the room, and R1 called for help while the sheet was still tied to the door. Another CNA said the door should not have been tied and described the action as abuse. The NP stated she was told R1 was detained in her room alone and that she was concerned about the resident being monitored in her manic state, but she did not feel comfortable with the resident being detained and later added an addendum after being pressured to change her note. The ADON acknowledged that a towel or sheet had been tied to the door and stated, “That’s abuse, involuntary seclusion.” The facility’s abuse policy defined involuntary seclusion as isolation of a resident against his/her will and included locking a resident in a room or area by themselves as an example.
Involuntary Seclusion of Resident in Locked Shower Room by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from involuntary seclusion when a CNA placed the resident in a locked shower room, unattended, for an extended period without the ability to exit. The facility’s own abuse and seclusion policy states that every patient has the right to be free from abuse and involuntary seclusion, defining abuse as unreasonable confinement with resulting mental anguish and involuntary seclusion as separation from others or confinement against the resident’s will. Despite this policy, the CNA removed the resident from his room while he was yelling out, pushed him in a geriatric chair into the shower room, and left him there with the door locked, without providing a shower and without the resident’s consent. The resident involved had diagnoses including generalized anxiety disorder, bipolar disorder, and major depressive disorder, and was documented on the quarterly MDS as cognitively aware (BIMS score of 12), non‑ambulatory, and dependent for ADLs. The resident later reported that he told the CNA he did not want to go into the shower room, did not want to be left there, and that he was left there against his will for a long time. Staff interviews and documentation indicated that the resident remained in the locked shower room for approximately 30 minutes to one hour. When an LPN checked on him, she found him alone in the locked shower room, seated in a reclined geriatric chair, with his face pink in color and having difficulty breathing, and another CNA heard the resident pleading to be let out and thanking staff when they entered. The CNA admitted in a subsequent interview that he placed the resident in the shower room and left him unattended because the resident was yelling out and he wanted the resident to quiet down and not disturb his roommate and other residents. He acknowledged that he did not provide a shower and stated he “just put him in there so that he would hush.” The resident expressed anger about the incident to both the LPN and Social Services, and the Administrator confirmed that staff reported the resident was locked in the shower room for 30 minutes to an hour and that such confinement constituted seclusion and abuse under facility policy. The incident was reported as staff‑to‑resident abuse to the State Survey Agency and law enforcement, and the facility documented that the resident experienced psychosocial harm as evidenced by his anger about being locked in the shower room against his will.
Locked Exit Doors Restricted Resident Freedom
Penalty
Summary
The facility failed to ensure residents were free from involuntary seclusion when it maintained locked exit doors that prevented residents from freely exiting the building without individualized assessments, clinical justification, physician orders, or care planning to support the restriction. Surveyors identified this issue as affecting 8 of 34 residents, including residents who were cognitively intact, independent with mobility, and documented as not being at risk for elopement or wandering. Record review showed that multiple residents had assessments and care plans indicating they were able to move about independently, use wheelchairs or walkers, go outside, and were not elopement risks. For example, residents were documented as having intact or moderately impaired cognition, independent transfers, independent wheelchair propulsion, and in some cases a desire to go outside for fresh air. Elopement risk evaluations for these residents repeatedly indicated they were not at risk for elopement. Despite this, the facility had no individualized assessments, care plans, physician orders, or other clinical justification in the records to support restricting their ability to leave the building. During interviews and observations, the administrator stated the doors were locked from the inside and outside for safety and security and that only staff had access to the codes. The administrator confirmed residents, including those who were independent and without cognitive impairment, could not leave the building without staff assistance and that no individualized assessments or waivers had been completed to support the restriction. Staff confirmed all facility doors were locked and residents could not independently exit. Surveyors observed several exit doors with keypads and push bars that remained locked when pressed, and one resident stated the locked doors made the facility feel "almost like jail." The medical director stated that individualized assessment, including elopement risk, cognition, physical ability, and decision-making capacity, would be expected before restricting a resident's ability to leave freely, and that a generalized safety concern could not be applied to all residents.
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