Complaint Investigation Report

During today's visit, LPA Ruiz observed full bed rails on 3 residents beds. Interviews and records review revealed that 2 of 3 residents are on hospice and 1 hospice resident has an order for full bed rails. Interviews revealed that the residents are placed in their beds and the bed rails are pulled into an upright position for residents between 3pm and 5pm. The Licensee stated that the bed rails remain in the upright position overnight and are lowered in the morning around 7:00am. Interviews revealed that the bed rails, chairs, and furniture are used to alert the Licensee if a resident is getting up while on the overnight shift. Interviews revealed that the full bed rails are used to prevent the residents from falling during the night.

The Department has investigated the above-mentioned allegation and based on interviews, record review, and observations, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Licensee Teresita "Roxie" Roxas, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.