complaint·June 28, 2022

Interviews and record review revealed that R1 is currently on hospice, and because R1 has skin integrity challenges, R1 has an order on file for heel protectors. A file review confirmed the order for the heel protectors, and an interview with a hospice nurse confirmed that upon visiting R1, R1 is always observed wearing the heel protectors. Staff confirmed that R1 is repositioned every two hours, as R1’s skin is susceptible to redness. As such, staff claimed that if R1 is observed facing the wall, staff believe R1 is facing the wall for a short period of time as R1 is repositioned every two hours. During today’s visit, the LPA observed R1, and observed that R1 was wearing their prescribed heel protectors. R1 was observed lying on their back and did not appear to be in distress. However, interviews and a review of the facility’s progress notes confirmed that at least on one occasion - on 06/05/2022 - R1 was found in bed with their pants around their ankle, and a pillow was observed between their legs. Whereas the pillow was used to prevent further skin integrity challenges, staff agreed that R1’s pants should have either stayed on or been completely removed. The presence of R1’s pants around their ankles restricts R1’s movement, thus unintentionally restraining R1. As a result of this incident, Reminiscence staff will receive an in-service training regarding the proper use of postural supports and maintaining a restraint-free environment. Based on the investigation, there is sufficient evidence to support the claim that staff are restraining resident in care. This allegation is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued.