Failure to Prevent Involuntary Seclusion Due to Improper Secure Unit Placement
Summary
The facility failed to ensure that a resident was free from involuntary seclusion and physical restraint not required to treat medical symptoms. A female resident with severe cognitive impairment, dementia, and heart failure was admitted and later placed on a secure unit. Documentation showed that initial elopement risk assessments indicated no risk, and there was no evidence of behavioral symptoms such as wandering or exit-seeking prior to her transfer. The resident's care plan and medical record did not contain orders or clear documentation justifying her placement on the secure unit at the time of transfer. Interviews with staff, including CNAs and LPNs, revealed that the resident had not exhibited exit-seeking behaviors or attempts to elope. Staff described her as forgetful and easily redirected, with occasional wandering only when searching for misplaced items. The resident herself did not express distress about her placement and participated in activities, but her family was not informed about the reason for her move to the secure unit and requested her return to the general population. The care plan was updated to reflect elopement risk only after the investigation began, and the elopement risk evaluation with a moderate risk score was not completed or available in the electronic medical record until after the surveyor's inquiry. Facility leadership, including the ADON and DON, could not provide consistent or documented reasons for the resident's placement on the secure unit, and there was no physician order for the move. The facility's policy on wandering and elopement did not specify criteria or procedures for secure unit placement. The lack of proper assessment, documentation, and communication regarding the resident's transfer to the secure unit constituted a failure to protect the resident from involuntary seclusion.
Penalty
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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.
Surveyors determined that two halls were functioning as locked, secured units requiring a keypad code for entry and exit, with no alternative unlocked access and no posted code. Facility leadership believed prior corporate actions and a dementia disclosure form were sufficient for secured-unit status and were unaware that state authorization was required; there was no policy, criteria, or program governing secured units. Record review for four residents on these halls showed physician orders allowing residence on a secured unit but no corresponding assessments or evaluations to identify the medical or behavioral symptoms being treated, and in several cases no care plans addressing the need for secured placement, despite MDS data showing little or no wandering or maladaptive behaviors.
A cognitively impaired, wheelchair-dependent resident with severe intellectual disability and multiple physical limitations was repeatedly confined to her room by a nurse, who pushed her into the room and shut the door because the resident was loudly vocalizing in the lobby. CNAs later found the resident in her room with the door closed, faintly yelling and knocking, and reported that she lacked the strength to open the door herself. The resident’s roommate heard commotion and the door being closed while the resident remained inside making noise until other staff opened the door. Afterward, staff observed bruising and swelling to the resident’s finger and bruising to the chest, and the resident persistently indicated that a nurse had hurt her and shut her in her room, consistent with the facility’s definition of involuntary seclusion.
Missing Physician and Resident Representative Signatures on Secured Unit Reviews: The DON confirmed that secured unit IDT evaluations for six residents lacked physician documentation of clinical criteria for continued placement and lacked required physician signatures. Two residents also had no resident or resident representative signature on the continued stay review. The affected residents had diagnoses including dementia, psychosis, mood disorders, anxiety, depression, and other cognitive impairments, and the facility policy required ongoing review and documentation for residents in a secure or locked area.
A resident with moderate cognitive impairment and multiple chronic conditions repeatedly called 911 at night due to perceived hallway noise. In response, an LVN and a CNA entered the room; the CNA held the resident’s arms down while the LVN removed the resident’s personal cell phone from his clothing and took it to the nurse’s station without consent. The resident’s wheelchair was also removed from the room to the hallway, and staff refused his requests to be assisted out of bed into the wheelchair, telling him to remain in bed. These actions, confirmed in staff interviews and contrary to the facility’s abuse prevention policy, resulted in the use of physical restraint, unreasonable confinement, and deprivation of the resident’s personal property and services.
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.
Locked Units Used as Secured Halls Without Authorization or Individual Justification
Penalty
Summary
Surveyors found that the facility failed to protect residents from involuntary seclusion by locking and securing two units (the 200 and 300 halls) without authorization from the Indiana Department of Health and without appropriate clinical justification for individual residents. During observations on two consecutive days, the double doors to the 200 hall were closed and locked, requiring an unposted keypad code for both entrance and exit, with no other unlocked access to the unit. The adjoining 300 hall (Swan unit) could only be accessed by passing through the locked 200 hall doors, also requiring a code, effectively making both halls secured units. Review of IDOH licensing records showed no authorization to occupy any secured unit within the facility. Interviews with the COO and Nursing Officer revealed that the facility leadership believed that submission of an FSSA dementia disclosure form met requirements for a secured unit and were unaware that IDOH did not license or authorize dementia units. They indicated that prior LSC and LTC survey teams had allowed the units to be secured, but they had no documentation of IDOH Division of Long Term Care approval or authorization for occupancy as secured units. The Administrator and DON further indicated there was no facility criteria, policy, or program related to the operation of secured units, and that they had assumed, based on prior ownership and corporate direction, that the 300 hall was an approved secured dementia unit and the 200 hall an approved secured behavioral unit. Record review for four residents residing on these locked units showed a lack of required assessments, evaluations, and care planning to justify placement on a secured unit. One cognitively intact resident with bipolar disorder and other psychiatric diagnoses had an order to reside on a secured unit but no assessment identifying the medical or behavioral symptoms being treated, and her MDS showed no wandering or maladaptive behaviors. Another resident with paranoid schizophrenia, bipolar disorder, and intellectual disabilities had an order to reside on a secured unit but no assessment or care plan for that need, with MDS data showing severe cognitive impairment but only limited rejected care and no documented wandering. A resident with dementia and PTSD had an order to reside on a secured unit and had been placed on the 300 hall due to a dementia diagnosis, but had no care plan for secured placement and no documented wandering or elopement attempts. A resident with Alzheimer’s disease and other psychiatric diagnoses had an order to reside on a secured unit and a significant change MDS showing memory loss and some wandering, but no assessment or evaluation identifying the medical or behavioral symptoms being treated by locked unit placement. Leadership confirmed that these residents were placed on the secured units based on diagnoses and perceived needs, without prior formal evaluation or care planning for secured placement.
Involuntary Seclusion and Resulting Injuries to a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from involuntary seclusion. The resident was admitted with severe intellectual disability, muscle wasting and atrophy, lack of coordination, abnormal posture, and osteoporosis, and was documented as severely cognitively impaired with a BIMS score of 5. The resident was dependent on staff for most ADLs, used a wheelchair, and required supervision or assistance for mobility. The care plan documented impaired cognitive function and communication problems, and an abuse/neglect screening identified the resident as at moderate risk for abuse, although the care plan did not reflect an abuse risk. On the night in question, multiple staff accounts and the facility’s final report to the state agency indicated that the nurse on duty pushed the resident into her room and shut the door because the resident was yelling in the lobby as other residents passed by. CNAs from the night and day shifts reported that the resident had been up front hollering, then was later found in her room with the door shut, faintly yelling and knocking, and that they had to open the door to let her out. Staff consistently stated that the resident did not have the strength or capability to open the door independently. The resident’s roommate reported hearing commotion between the resident and a staff member, followed by the door being closed while the resident remained in the room making noise, until other staff opened the door and the resident left. Following the incident, staff observed bruising and swelling to the resident’s left index finger and bruising to the chest. The facility’s final report documented that the investigation revealed the nurse had pushed the resident into her room and shut the door, and that the resident reported knocking on the door, which was associated with bruising to her finger. Multiple staff interviews documented that the resident repeatedly pointed to her bruised areas and door, saying variations of “nurse hurt me,” “nurse my room,” and “nurse door.” The facility’s abuse policy defined unreasonable confinement or involuntary seclusion as separation of a resident from others or confinement to the room against the resident’s will, and the incident was characterized as abuse involving involuntary seclusion of the resident in her room multiple times.
Missing Physician and Resident Representative Signatures on Secured Unit Reviews
Penalty
Summary
The facility failed to ensure documentation of physician participation in the Interdisciplinary Team (IDT) review for continued placement in the secured unit for six residents: Resident #4, #23, #49, #71, #72, and #88. The facility also failed to ensure that the resident or resident representative signed the IDT review for continued placement in the secure unit for Resident #72 and Resident #88. The deficiency was identified through review of the facility policy, secured unit placement documentation, medical records, and staff interview. The facility policy titled, Secure Unit Placement, stated that residents in a secure or locked area must be free from involuntary seclusion and that ongoing evaluations should be conducted as indicated. The policy also stated that the resident's medical record should reflect documentation of the clinical criteria met for placement in the secure or locked area by the resident's physician, along with information provided by members of the interdisciplinary team, and ongoing documentation of review and revision of the care plan as necessary, including whether the resident continues to meet criteria for remaining in the secured or locked area. Resident #4 had diagnoses including delusional disorders, unsteadiness on feet, protein calorie malnutrition, psychosis, anxiety disorder, depression, adjustment disorder, malignant neoplasm of breast, and vascular dementia, and had BIMS scores indicating severe cognitive impairment. Resident #23 had diagnoses including vascular dementia, unsteadiness on feet, generalized anxiety disorder, repeated falls, mood disorder, delusional disorders, major depressive disorder, and history of traumatic brain injury, with BIMS scores showing severe cognitive impairment and later moderate cognitive impairment. Resident #49 had diagnoses including Alzheimer's disease, dementia with severe agitation, frontal lobe and executive function deficit, delusional disorders, depression, anxiety disorder, and history of traumatic brain injury, with BIMS scores showing severe cognitive impairment. Resident #71 had diagnoses including fracture of the left femur, vascular dementia, anxiety disorder, protein calorie malnutrition, and adjustment disorder with mixed disturbance of emotions and conduct. Resident #72 had diagnoses including Alzheimer's dementia with early onset, dementia with psychotic disturbance, anxiety disorder, bipolar disorder, schizophrenia, major depressive disorder, and mood disorder, with BIMS scores showing moderate cognitive impairment and later cognitive intactness. Resident #88 had diagnoses including vascular dementia, unspecified symptoms and signs involving cognitive functions and awareness, delusional disorders, adjustment disorder, and protein calorie malnutrition, with documentation of moderate cognitive impairment for decision making and diagnoses including non-traumatic brain dysfunction and non-Alzheimer's dementia. For each of these residents, the Secured Unit Continued Placement Evaluation documents reviewed for the secured unit contained no documentation of the clinical criteria by the physician for continued placement and no physician signature for participation in the IDT review. For Resident #72 and Resident #88, the documents also lacked the resident or resident representative signature showing participation in the IDT review for continued stay in the secure unit. During interview, the DON confirmed that the IDT Secured Unit Evaluations did not contain the required physician documentation or required signatures for these residents and stated that the evaluation documents did not contain an area for physician signatures.
Abusive Use of Physical Restraint and Removal of Resident Property During 911 Call Incident
Penalty
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.
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