F0603

K

Involuntary Seclusion of Dependent Resident in Vacant Bathroom

Brenham, Texas Survey Completed on 02-21-2026

Penalty

No penalty information released

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).