The incident at Douglas Jacobson State Veterans Nursing Home left the alert and oriented resident feeling "angry and embarrassed" as he tried to make it back to his room before a scheduled doctor's appointment on July 25.
"They wouldn't let him use the restroom," the veteran told state inspectors during an August interview. "PT Staff D threw a wheelchair in front of the bathroom door to block him from entering."
The resident had been living at the facility for nine years and said he had "always been treated with respect and dignity by all the employees except for this incident."
He was dressed and heading to catch his ride for the doctor's appointment when he suddenly realized he needed to defecate. The physical therapy room was right there.
The three therapists refused to let him use the bathroom. None of them requested assistance from the nursing department or notified nurses of his need.
The veteran tried to make his way back to his room but couldn't make it in time.
"The incident made him feel angry and embarrassed," he told inspectors. "He said that behavior cannot be tolerated."
The resident has Parkinson's disease and Alzheimer's disease but scored 15 on a mental status assessment in July, indicating intact cognition. Due to back issues, he can only stand for about 10 seconds before losing his balance.
His care plan noted he needed assistance with transfers but was capable of toileting himself. Therapy notes recommended staff be present to prevent falls, but the therapists never offered personal assistance with the restroom.
"Resident #1 was offered assistance to get back to his room but never assistance with the toilet," according to the inspection report.
The facility's own Director of Rehab said there was no excuse for the therapists' actions.
"Their verbal policy is to accommodate all residents to use the restroom," she told inspectors. She wasn't working the day of the incident but was told the resident had stopped in saying he needed the bathroom.
The director said she even keeps tape in front of the bathroom door "to ensure it stays free of clutter and not blocked."
"There was no excuse for denying the resident access to the therapy bathroom," she said.
The three therapists involved were contracted from an outside company that provides physical therapy services to all state facilities, according to administrators. The Regional Administrator, Risk Manager, and Assistant Director of Nursing told inspectors they were aware of the incident that resulted in the veteran soiling himself.
The veteran emphasized to inspectors that he didn't require assistance to use the restroom. The therapists are professionally trained to assist with standing and pivoting, but they chose to block access entirely rather than provide appropriate supervision.
The facility's own policies contradicted the therapists' actions. The Director of Rehab's verbal policy specifically called for accommodating all residents who needed bathroom access, and she had taken physical steps to keep the bathroom door clear.
The incident violated the resident's right to dignity and respect. Federal regulations require nursing homes to treat each resident with dignity and respect, recognizing their individuality.
For a veteran who had lived at the facility for nearly a decade without incident, the bathroom blocking represented a stark departure from the respectful treatment he had come to expect.
The timing made the violation particularly cruel. The resident was prepared for his medical appointment, dressed and ready to leave, when a basic human need arose. Instead of receiving appropriate assistance or accommodation, he faced a physical barrier deliberately placed to deny him access.
The wheelchair blocking the door wasn't an oversight or accident. It was a deliberate action by PT Staff D to prevent the veteran from entering the bathroom, despite facility policy and basic standards of human dignity.
The resident's embarrassment and anger reflected the profound impact of being denied such a fundamental need. After nine years of respectful treatment, the incident stood out as an unacceptable breach of the dignity he deserved as both a resident and a veteran.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Douglas Jacobson State Veterans Nursing Home from 2025-08-21 including all violations, facility responses, and corrective action plans.
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