Complaint Investigation Report

During today’s visit, LPA requested copies of resident and staff rosters. At approximately 11:40am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. No full bed observed on residents' beds.

Allegation: Licensee used full bed rails for non-hospice resident.

It was reported and stated by RP that on 08/27/2024, s/he noticed full bed rails were installed on R1's bed. RP states s/he believes the full bed rails were placed on R1's bed as a way to restrain him and keep him in bed. RP also states the full bed rails were still in place on 09/10/2024 when they moved R1 out to another facility. To investigate this allegation, LPA conducted interviews and collected R1's records for review. Based on interviews with the facility Administrator and two (2) caregivers, it was revealed that the Resident #1 (R1) was observed attempting to get out of bed independently despite his/her health condition requiring assistance. All staff members stated that R1 was at high risk of falling from the bed. In an effort to prevent a fall, staff utilized a full bed rail on R1's bed. Staff also stated that multiple times they asked R1's POA to speak with the physician to get R1 re-evaluated and request full bed rail order if with physician's approval. POA never requested stating R1 does not need full bed rail. LPA reviewed R1's records and observed that R1 was receiving Palliative care, however, there was no physician's order for the use of full bed rail at that time. Per Title 22 regulations, the use of full bed rail without a doctor's order constitutes a violation of the regulation. Based on observations, interviews, and records review there is sufficient evidence to conclude that the above allegation is Substantiated.

Deficiency issued per CA code of Regulations Title 22 on LIC-9099D

Exit interview conducted, appeal rights explained, and a copy of this report signed and delivered.