Involuntary Seclusion of Dependent Resident in Vacant Bathroom
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).
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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