F0603

D

Abusive Use of Physical Restraint and Removal of Resident Property During 911 Call Incident

Baytown, Texas Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from abuse, including physical restraint, unreasonable confinement, and deprivation of property and services. The resident was an adult male with a history of vitamin deficiency, pain, hypertensive heart disease, type 2 diabetes, and muscle weakness. His quarterly MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and his care plan identified potential risk for impaired cognitive function or thought processes related to psychotropic drug use, history of stroke, and mild cognitive impairment. His care plan interventions included using his preferred name, identifying oneself at each interaction, reducing distractions, using simple directive sentences, and providing cues, reorientation, and supervision as needed.

On the night of the incident, the resident repeatedly called 911 from his room due to noise in the hallway that he felt was preventing him from sleeping. According to interviews and the facility’s investigation, he placed approximately 14 calls to 911 within about 10 minutes. Law enforcement contacted the facility and requested staff intervention. In response, staff members identified as an LVN and a CNA went to the resident’s room. During this encounter, the resident reported that one staff member held his arms down while the other removed his personal cell phone from the front of his clothing and took it to the nurse’s station, telling him it would be returned in the morning. The resident stated that he felt physically restricted during this interaction and that staff took his cell phone without his consent.

The resident further reported that his wheelchair was removed from his room and placed in the hallway. He stated that he requested assistance to be transferred into his wheelchair and to leave the room, but staff refused his request, instructing him to remain in bed because it was late. He indicated that he could not get up independently and required two-person assistance. Interviews with the DON, LVN, and CNA confirmed that the CNA held the resident’s hands while the LVN removed the phone, and that holding the resident down was recognized as a form of physical restraint. The removal of the resident’s wheelchair from his room and the refusal to assist him out of bed restricted his movement. The facility’s abuse prevention policy defined abuse to include willful infliction of injury, unreasonable confinement, and deprivation of goods or services necessary to maintain physical, mental, and psychosocial well-being, and staff acknowledged that holding a resident down and removing personal property such as a phone without consent met this definition.