Complaint Investigation Report

The department reviewed resident #1’s (R1) service file and received the following documents: Admission Agreement (dated: 03/06/26), Physician’s Report (LIC 602), Preplacement Appraisal Information, Needs & Services Plan (dated: 03/09/26), and Physician order (dated: 04/06/26). Additionally, the department conducted interviews with staff #1-#3 (S1-S3), witnesses #1-#2 (W1-W2), residents #1 (R1), #5-#6 (R5-R6), and attempted to interview residents #2-#4 (R2-R4). Furthermore, the department conducted a tour of the facility.

The investigation revealed the following:

Allegation: Staff are inappropriately restraining a resident resulting in injuries. It is being alleged that a resident sustained bruising to their wrists and ankles due to facility staff restraining them. Record review of R1’s Admission Agreement dated 03/06/26 confirms that R1 was admitted to the facility on 03/06/26. Review of the Physician’s Report dated 03/06/26 indicates that R1 is ambulatory. The department reviewed R1’s Appraisal/Needs and Services Plan dated 03/09/26 and did not observe any documented need for postural supports or restraining devices. Record review of a physician’s order dated 04/06/26 reflects an order authorizing full side rails and a self-releasing seat belt for R1.

On 05/06/26, the department conducted a tour of the facility and observed all residents present. During the tour, no bruising was observed on any resident’s wrists, and/or ankles.

On 05/06/26, the department conducted interviews with S1–S3. Of those interviewed, 3 out of 3 staff denied the allegation and stated they do not restrain residents without a physician’s order. However, during the interview, S1 disclosed that a wheelchair seat belt had been placed on R1 without a physician’s order from the time of admission until approximately one month ago. S1 stated the seat belt was used depending on R1’s behavior and sundowning episodes and was discontinued once staff were informed that no physician’s order existed. An interview with S2 revealed that a self-releasing seat belt is used on R1 at times, depending on behavior. S2 stated there is a physician’s order authorizing a self-releasing seat belt and full side rails for R1.