Complaint Investigation Report

Allegation: Staff installed bed rails on resident's bed without proper authorization

On 05/01/24 LPA spoke to RP who stated that R1 stated to them that they felt like they were in "a cage." RP further explained that R1 stated that the bed rails on the bed made them feel like they were in a cage. RP stated that S1 said that R1 was a fall risk and that the bed rail was for safety. RP stated that R1 did not have a doctor's order for a bed rail, but the staff removed the bed rail while RP was at the facility on 04/22/24. LPA interviewed R1 and R1 stated that the bed rail was on the bed initially but the Staff removed the bed rail. LPA reviewed R1's Physician Report and the report did not have any information that reflected the use of a bed rail for mobility support. LPA observed that the bed rail was removed on R1's bed. LPA advised S1 that bed rail for postural and mobility support requires a doctor's order. Based on information that S1 admitted that there was a bed rail on R1's bed the allegation is substantiated.