complaint·August 14, 2024

Staff are not following a resident's physician's order. On the allegation that staff are not following a resident’s physician order; the Reporting Party (RP) stated that on 8/6/2024, a staff removed the bed rails from the resident's (R1) bed because the facility's corporate office stated that bed rails are prohibited at the facility. LPA Urena interviewed the RP on 08/12/2024 from 2:49 p.m. to 3:20 p.m. The RP stated that R1 had a physician’s order for the half bed rails since October 2023; the bed rails were ordered by the physician due to R1 having a history of falling, and R1 is currently receiving hospice care and have a hospice care plan that specifies the need for half bed rails. Furthermore, the RP stated that facility’s corporate office staff made a visit to the facility and ordered bed rails to be removed as of August 6, 2024. The facility’s corporate office staff made the decision to return the bed rails and installed them back on R1’s bed. However, the RP stated that they have witnessed on several occasions that the bedrails are always in the lower position, versus the raised position to prevent R1 from falling out of the bed. R1 stated that they are not aware of the facility’s policy on prohibiting bed rails. The admission agreement signed by the RP does not have the facility’s policy stated on the agreement. To investigate the allegation, the LPAs reviewed R1’s physician report (LIC 602A), Admission Agreement (LIC 604A), Hospice Plan, physician’s order for bedrails, facility policy on bedrails and/or notification to residents in care about the facility’s bedrail policy. The record review revealed that R1 has a physician’s order for half bed rails dated 12/26/2023. The Admission Agreement (21 pages) does not specify the facility’s policy on bed rails. Based on the information obtained through interviews and record review; the information revealed that although the half bed rails were removed only temporarily and have been re-installed on R1’s bed, the facility staff failed to inform the R1’s responsible parties of the facility’s policy implementation, and the facility staff failed to follow the resident's physician's order. Therefore, this allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.