Complaint Investigation Report

Allegation: Staff put up full bed rails on resident's bed without Physicians orders

During record review and interview, LPA discovered that R1 was admitted to hospice care on 5/15/2025. LPA reviewed R1's hospice care plan dated 12/17/2025 on page 12 that it states, "Full bed rails with rail pads for safety" was ordered and approved for R1's care. LPA also reviewed two of R1's physicians order's. The first physicians order dated on 8/11/2025 orders "Full bed rails with rails pads for safety" and the second physicians order dated 4/13/2026 orders "Hospital bed with full rails with rails pads safety."

Allegation: Staff used bed rails as a restraint for resident

LPA observed that R1 is able to adjust themselves but receives assistance to get into their wheel chair. LPA observed that the full bed rails have a an adjustment tool that allows the rails to go down when R1 wants to get out of bed.

Based on interviews and record review during visit, the allegations that Staff put up full bed rails on resident's bed without Physicians orders and Staff used bed rails as a restraint for resident was found to be unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit Interview conducted with Nancy and copy of this report provided.