Failure to Prevent Involuntary Seclusion and Unauthorized Restraint
Summary
Facility staff failed to protect a resident's right to be free from involuntary seclusion. The incident involved a male resident with severe cognitive impairment, major depressive disorder, anxiety disorder, unspecified dementia, and Alzheimer's disease. The resident had a history of elopement and was admitted to a secure unit. On the day of the incident, the resident exhibited behaviors such as wandering into other residents' rooms, taking items, and becoming agitated when items were removed from him. He escalated to physically aggressive behaviors, including pushing a bedside table into a nurse, swinging a call light cord with a metal prong, and chasing staff down the hallway. Staff responded by physically restraining the resident, carrying him by his extremities without supporting his back or midsection, and placing him in his room. They then held the door closed, preventing him from leaving, while he struggled to get out. During the incident, staff did not attempt de-escalation techniques or remove other residents from the area as outlined in the resident's care plan. Instead, they focused on isolating the resident in his room and physically restraining him. The staff took turns holding the door closed, and the resident was left unsupervised inside the room, where he continued to display agitation, including breaking a window. The police and EMS were eventually called, and the resident was further restrained by law enforcement and administered medication by a hospice nurse. Interviews with staff revealed that the decision to seclude and restrain the resident was made collectively, and some staff expressed discomfort with the way the situation was handled. The facility's policies prohibit the use of unauthorized restraints and involuntary seclusion. However, staff actions during the incident did not align with these policies. The Director of Nursing and Administrator were not fully informed of the severity of the incident until after reviewing video footage. The resident's power of attorney was not notified in a timely manner, and there was no documentation of consent for the use of restraints or medication. The incident resulted in skin tears to the resident's finger and arm, and the resident was unable to recall the event during subsequent assessment.
Removal Plan
- Staff members LVN A, RN and NA were immediately suspended by the administrator. All three staff members remain suspended.
- Resident #1 had a head-to-toe assessment completed by the charge nurse. The skin tears to resident #1's finger and upper arm are being treated according to physician orders.
- Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts.
- The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents.
- Safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted.
- Head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses.
- Staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility.
- The medical director was notified of the immediate jeopardy by the Administrator.
- An ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal.
- The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies: Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement; All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse; Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent; Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement; Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident; Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe; De-escalate the behavior by giving the resident space; Monitor the residents from a safe distance; Provide 1:1 monitoring until further directed by the abuse coordinator; Staff will not restrain a resident or seclude a resident involuntarily.
- The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment: Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement; All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse; Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent; Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement; Trauma informed Care to include unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma; Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe; De-escalate the behavior by giving the resident space; Monitor the residents from a safe distance; Provide 1:1 monitoring until further directed by the abuse coordinator; Staff will not restrain a resident or seclude a resident involuntarily.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with advanced dementia, agitation, psychotic disturbance, and elopement risk was moved to a secure/locked unit without an active physician order documenting the criteria for that placement. The DON stated the resident had been assessed, the family/representative agreed, and the move was intended to provide more supervision and a quieter environment, but the required order was overlooked before the transfer.
A secured unit placement deficiency occurred when three residents were housed on the locked unit without physician orders or documented criteria supporting admission. Record review showed one resident with severe cognitive impairment, one with vascular dementia and no BIMS recorded, and one with moderate cognitive impairment; none had wandering behavior documented, and care plans did not support secured-unit placement except for one note that the resident may be housed there. The MD, DON, and Administrator all confirmed the lack of orders, and the facility policy required a physician order and resident criteria for secure-unit admission.
A resident who was documented as cognitively intact and without a dementia diagnosis was transferred from an LTC unit to a locked dementia unit. After the move, the resident repeatedly expressed distress and stated she did not belong there, while psych and nursing notes documented anxiety, tearfulness, mood lability, social isolation, and emotional outbursts related to the unit transfer.
A resident with quadriplegia and total ADL dependence was placed on a toilet in a locked common bathroom and then left unattended when a CNA left the facility without notifying staff. Because the call light was not functioning, the resident had to get himself off the toilet, crawl to the door, and bang for help before staff found him on the floor hours later. He later reported wrist pain and described feeling abandoned, angry, miserable, and fearful after the incident.
Improper Placement of Residents on Secured Unit: The facility placed multiple residents on a secured unit without documented physician orders, documented IDT review, or evidence of assessment supporting the placement. Several residents had low elopement-risk findings and no documented history of elopement, while others had dementia or other cognitive diagnoses and were observed in the secured unit or common areas despite the lack of documentation supporting locked-unit admission.
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.
Missing Physician Order for Secure Unit Placement
Penalty
Summary
The facility failed to ensure one resident was free from involuntary seclusion when the resident was moved to a secure/locked unit without a physician order documenting the clinical criteria for that placement. Resident #7 was a female with diagnoses including Alzheimer’s disease, severe dementia with agitation, severe dementia with psychotic disturbance, insomnia, anxiety disorder, and major depressive disorder. Her quarterly MDS showed a BIMS score of 01, indicating severely impaired cognition, and her care plan identified her as high risk for elopement and noted she had attempted to leave the facility several times. The record showed that the resident’s representative signed a secure unit acknowledgment form stating the resident preferred the secure unit and did not wish to move, with elopement risk listed as the reason. On 08/04/2026, the resident was observed in the common area of the secure/locked unit, and RN B stated the resident had been moved there that day for wandering and agitation. During attempted interviews, the resident was unable to state where she was living or whether she knew the door code, and she was not oriented to time or place. The DON stated the facility’s policy was to obtain a physician order before placing a resident in the secure/locked unit, and that the resident had been assessed and found to meet criteria for the unit. The DON also stated the resident’s representative agreed with the move and that the physician order was overlooked and not obtained before the transfer. The order was later entered into the chart, but at the time of the move there was no active physician order for placement in the secure/locked unit.
Missing physician orders for secured unit placement
Penalty
Summary
The facility failed to ensure three residents admitted to the secured unit were free from involuntary seclusion and failed to have physician orders for their placement in that unit. Record review showed Resident #1 was a 68-year-old male with diagnoses including drug induced subacute dyskinesia, schizoaffective disorder, bipolar type, and PTSD. Resident #2 was a 71-year-old male with diagnoses including cerebral infarction due to occlusion or stenosis of the left posterior cerebral artery, generalized anxiety disorder, and vascular dementia. Resident #3 was a 71-year-old male with diagnoses including COPD and bipolar disorder. Record review of the residents’ MDS assessments showed Resident #1 had a cognitive score of 0 with no wandering behavior, Resident #2 had no BIMS score recorded and no wandering behavior, and Resident #3 had a cognitive score of 8 with no wandering behavior. Their care plans did not include a focus or interventions for residing in the secured unit, except for Resident #3, whose care plan noted he was at risk for wandering/elopement and that he may be housed on the secure unit. Review of the facility physical orders showed no physician orders for any of the three residents to reside in the secured unit. During interviews, the MD stated there should be an MD order for a resident to be admitted to the secure unit and agreed proper documentation should be present. The DON stated no orders had been placed for the three residents to be in the secured unit and acknowledged residents should have the least restrictive environment. The Administrator also confirmed there were no orders for the three residents to be in the secure unit. The secured unit policy stated residents must meet medical and cognitive criteria for placement and that a physician’s order to admit to the secure unit is required.
Involuntary Seclusion Related to Transfer to Dementia Unit
Penalty
Summary
The facility failed to ensure one resident was free from involuntary seclusion when R182 was transferred from a long-term care unit to the locked dementia unit despite being documented as cognitively intact. R182 was admitted with diagnoses including anxiety and depression, and an admission MDS documented a BIMS score of 15 with no behaviors and no diagnosis of dementia. Social services documented that both the resident and the resident’s daughter were informed of the room change and were agreeable, but subsequent records show the resident was moved to the dementia unit and continued to express distress about the transfer. After the move, psychiatric and psychological notes repeatedly documented that R182 was upset about being placed on the dementia unit, stating she did not belong there and believed she still had all her mental faculties. Staff documented anxiety, tearfulness, mood lability, social isolation, intermittent emotional outbursts, and perseveration related to the unit transfer, while also noting the resident was alert and oriented and had no psychosis. The quarterly MDS later documented verbal behaviors during the assessment period, but did not document dementia, physical behaviors, or elopement risk.
Resident Left Unattended in Locked Bathroom Without Working Call Light
Penalty
Summary
The facility failed to ensure a resident was free from involuntary seclusion when he was left alone in a locked common bathroom after being placed on the toilet by a CNA. The resident had diagnoses including toxic encephalopathy, peripheral vascular disease, quadriplegia, traumatic brain injury, major depressive disorder, anxiety disorder, delusional disorder, and antisocial personality disorder. He was cognitively intact, dependent for all ADLs, used an electric wheelchair with setup assistance, and required a mechanical lift for transfers. According to the record and interviews, the resident was placed on the toilet in the common bathroom and then left unattended when the CNA left the facility without telling staff. The bathroom required a code to open, and the resident was unable to call for help because the call light system was not functioning. The resident later placed himself on the floor, crawled to the wall, and banged on it to get attention. Staff later found him on the bathroom floor near the door after he had been missing for approximately two to four hours. The resident reported that he had been left on the toilet for over four hours, that he had to push himself off the toilet and scoot to the door for help, and that he experienced pain in his wrist after crawling. A progress note documented swelling and pain in the left wrist, and an x-ray showed no acute fracture or dislocation. The resident described feeling abandoned, angry, miserable, and fearful after the incident, and the record showed no evidence that his psychosocial concerns were assessed or treated after the event. Interviews with staff were inconsistent about who assisted the resident, whether another staff member was involved, and whether the call light system was working at the time.
Improper Placement of Residents on Secured Unit
Penalty
Summary
The facility failed to ensure 7 of 7 residents reviewed for admission to the secured unit were free from involuntary seclusion. Residents #4 through #10 were placed on the secured unit even though their records showed low elopement risk, no documented history of elopement for several of them, no physician’s order for placement on the secured unit, and no documented interdisciplinary team decision supporting the placement. The report states there was no documentation that these residents were assessed for secured-unit placement before admission to the unit. Resident #4’s record showed diagnoses including arthritis, non-Alzheimer disease, seizure disorder, and malnutrition, with a BIMS score of 10 indicating moderate impairment. She had a physician’s order to be placed on the secured unit, but the record contained no documentation of assessment, prior elopement risk, or IDT discussion. Her elopement risk assessment coded her as low risk. During observation, she was in the secured unit, alert with some confusion, and told the surveyor she wanted to go home. Resident #5 had diagnoses including non-Alzheimer disease, hypertension, and unspecified dementia, with a BIMS score of 10 and no behaviors. There was no physician’s order for secured-unit placement and no documentation of assessment, prior elopement risk, or IDT discussion. Resident #6 had diagnoses including arthritis, non-Alzheimer disease, and malnutrition, with a BIMS score of 10. The record showed no order for the locked unit and no documentation of assessment, prior elopement history, or IDT discussion; the chart noted an overnight incident in which the resident pulled the exit door alarm, walked out, was brought back by CNA staff, placed on 1:1, and then moved to the secured unit the following day. Resident #7, Resident #8, Resident #9, and Resident #10 also had records showing cognitive impairment or dementia diagnoses, low-risk elopement assessments, no physician’s order for secured-unit placement, and no documentation that the residents were assessed or that the IDT discussed placement before they were admitted to the secured unit. Observations showed these residents in the secured unit or in common areas, including asleep in the lobby, in bed, or in activity, with varying levels of confusion or inability to respond.
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.
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