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:
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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