F0609

D

Failure to Report Allegation of Involuntary Seclusion to State Agency

Newton, Iowa Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report an allegation of abuse, specifically involuntary seclusion, to the State Agency for one resident. Resident #7 had cerebral palsy, severe intellectual disabilities, a history of healed traumatic fractures, was dependent on staff for most activities of daily living, and had a BIMS score of 1/15 indicating severely impaired cognition. Care plan entries documented that the resident liked to spend time in the common area watching TV, listening to music, and people watching, and that he could express basic needs through body language and simple verbalizations. The facility’s Abuse Policy defined abuse to include involuntary seclusion and required reporting to the State Agency within 2 hours, along with a timely and thorough investigation.

On a day when Staff A CNA was documented as providing care to the resident, Staff E CNA reported that the resident was making vocalizations and that Staff A placed him in his room and closed the door so she would not have to hear him, leaving him there for 45 minutes to an hour despite his preference to be in the common area. Staff E stated she reported this to Staff F RN, and the resident’s roommate confirmed that staff sometimes shut the door when the resident wanted out of the room. Staff F initially denied knowledge of such actions but then acknowledged that Staff E had reported that Staff A placed the resident in his room and closed the door, and that the roommate had activated the call light. The DON and Administrator both stated that such an incident should have been reported as an allegation of abuse and investigated, but neither had received a report of this allegation. The facility lacked documentation that the allegation was reported to the State Agency prior to 2/25/26, contrary to its abuse reporting policy.