Douglas Jacobson State Veterans Nursing Home

personally assisting (Resident #1) to the restroom.

The therapists are professionally trained to assist with standing and pivoting individuals. (Resident #1) was offered assistance to get back to his room but never assistance with the toilet nor was he allowed to toilet himself due to placing a wheelchair in front of the bathroom door.

The three individuals never requested assistance from the nursing department nor notified them of his need. (Resident #1) is alert and oriented and is capable of toileting himself but is recommended by therapy to have staff present to prevent falls per therapy notes.On 8/20/25, review of the clinical record for Resident #1 revealed an admission date of 3/4/21.

Diagnoses included Parkinson's disease, Alzheimer's disease.

Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 7/28/25 revealed Resident #1 scored 15 on the Brief Interview for Mental Status, indicating intact cognition.

The care plan initiated on noted the resident assistance of 1 for transfers (stand and pivot). Resident #1 also used a sit to stand lift when requested. On 8/20/25 at 10:30 a.m., in an interview the Regional Administrator, Risk Manager, and Assistant Director of Nursing said they were aware of the incident of Resident #1 not being allowed to use the restroom in the Physical Therapy Department which resulted in Resident #1 soiling himself.

They said all three therapists involved in the incident were contracted from an outside company to provide Physical Therapy services to all state facilities. On 8/20/2025 at 12:45 p.m., in an interview Resident #1 said the incident on 7/25/2025 made him very angry. He said that he was dressed and, on his way up front to catch his ride for a doctor's appointment. He said he suddenly realized he needed to poop and the Physical Therapy room was right there.

They wouldn't let him use the restroom. He said PT Staff D threw a wheelchair in front of the bathroom door to block him from entering. He said he tried to make his way back to his room but soiled himself before he made it back. Resident #1 said the incident made him feel angry and embarrassed. He said that behavior cannot be tolerated. He said he has been a resident at the facility for 9 years now and has always been treated with respect and dignity by all the employees except for this incident. Resident #1 said he did not require assistance to use the restroom.

Due to his back issues, he can only stand for about 10 seconds before he loses his balance. On 8/21/2025 at 9:45 a.m., in an interview the Director of Rehab said she was not working on 7/25/25 but was told Resident #1 stopped in and said he needed to use the restroom.

She said their verbal policy is to accommodate all residents to use the restroom.

She said she even has tape in front of the bathroom door to ensure it stays free of clutter and not blocked.

She said there was no excuse for denying the resident access to the therapy bathroom.

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