Complaint Investigation Report

Regarding the allegation: Facility did not provide resident an adequate bed.

It was alleged that the bed provided to R1 was inadequate. Interviews with staff and a hospice representative confirmed that the hospital bed was provided by the hospice agency, which was further confirmed by a review of the hospice order. Staff interviews confirmed that as needed, they would switch out R1’s mattress. Based on the information obtained through interviews and record review, there is insufficient evidence to support the claim that the facility failed to provide an adequate bed for R1, as the bed was provided by the hospice agency. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility staff did not provide resident movement outside of bed.

It was alleged that R1 was not moved from their bed. Resident interviews from 1/14/2022 revealed that two (2) out of five (5) residents mentioned they were moved from their bed once within that week. Residents interviews conducted on 12/20/2022 revealed that two (2) out of three (3) residents were assisted with being moved out of bed as needed. Staff also alleged that R1 was moved out of the bed ‘daily’ but also alleged that R1 did not like to move from their bed. An interview with staff and a hospice representative revealed that R1 experienced shortness of breath upon minimal exertion and mentioned that moving out of bed was sometimes challenging for R1. Staff noted that they assisted R1 with light exercises as instructed by hospice and would try to get R1 to move their extremities as often as possible. A review of hospice visiting notes indicated that upon visiting R1, R1 was observed out of bed and either sitting in a chair in their room or in the living room: 4/12/2020, 5/13/2020, 5/23/2020, 5/27/2020, 7/4/2020, 9/23/2020, 2/1/2021, 3/24/2021, 4/5/2021, 4/12/2021. However, this is not a complete indication of how often staff took R1 out of bed. Based on the information obtained, there is insufficient evidence to support the claim that the staff did not provide the resident movement outside of bed. Although the allegation may have happened, there is insufficient evidence to prove the claim at the time the complaint was received. The allegation is Unsubstantiated at this time.

Regarding the allegation: Residents beds had full rails.

It was alleged that R1 had full bed rails, and possibly without an order. Record review and interview revealed that R1 received the bed from the hospice agency. Although the hospice paperwork indicated that R1 had a hospital bed with half-rails, further records review confirmed that there was a separate signed order on file from R1’s physician for R1 to have a full bed-rail. Photo evidence and interviews confirmed that R1 had a full bed-rail on their bed. Based on the information obtained through interviews and record review, there is insufficient evidence to support the claim that R1’s bed had full rails without an appropriate order. This allegation is deemed Unsubstantiated at this time.