Complaint·November 29, 2022

The investigation revealed the following... Regarding the allegation: Staff forced resident to walk without needed assistance while in care. It’s being alleged that a staff demanded a resident get up and walk without allowing another staff to help the resident into a Hoyer lift to get to their walker. On 11/29/2022, LPA attempted interviews with 5 out of a total of 56 residents. 4 out of 5 could not confirm the allegation. LPA was unable to interview 1 resident due to their developmental cognition. R1 states, “They wanted me to get up and walk. They didn’t force me, but they said, “well if you can walk, get up and walk.” R2 states, “I use my walker when I’m outside the room. Inside my room, I walk without it, but the staff don’t dictate when and when not to use it. If I need assistance, they help me.” R3 states, “when I first came, I used a walker but now only sometimes. No one ever forces me to not use it.” R4 states, “neither, I’m grown. I do what I want with my walker.” During interviews with staff, LPA interviewed 4 out of 33 in total. 0 of the 4 confirmed the allegation. S1 states, “R1 has not been able to walk since the day they came here. No one would demand them to walk. R1 says they can walk and turn by themselves, but they really can’t.” S2 states, “first of all, since R1 came here, they haven’t been able to walk so I’m confused. They never walked since day one.” S3 states, “I asked R1 if they wanted to try walking in front of me and the doctor and I would help them, but they refused. They didn’t want to do it and didn’t want help from us. They just kept saying I could do it myself.” S4 states, “we were never told not to help R1. They were never forced to walk because they can’t. R1 would try to tell us that they don’t want our help and S3 tells us we have to respect their wishes but still always offer R1 help.” Regarding the allegation: Staff are confining resident to their bed while in care. It’s being alleged a staff has instructed other staff to not help a resident move. Leaving them stuck in bed unable to get to their walker. 3 out of 5 could not confirm the allegation. 1 confirmed the allegation. LPA was unable to interview 1 resident due to their developmental cognition. R1 states, “yes, they confine me to the bed. The staff were told to cut down on helping me, but they help me anyway. I got so upset, I told them I would do it myself. I was really upset and that’s when they went downstairs and told them don’t help me. And to help me as less as possible.” R2 states, “I’m never confined to my room. I can come out any time I want.” R3 states, “I’m not confined to my room or bed. I don’t have any problems here.” R4 states, “the only time we have been confine to our rooms was during covid but now we are free to move around. Never observed anyone being confined against their will.” Cont on 9099C During interviews with staff, 0 of the 4 confirmed the allegation. S1 states, “R1 is bedridden and has always been. They were admitted bedridden.” S2 states, “R1 never walked since day one. We help them while in bed. We give them a sponge bath in bed since they moved here so we are not confining them.” S3 and S4 both state the resident is not confined but is bedridden and requires the use of a Hoyer lift. LPA Agard reviewed the following records: a staff roster not dated. All staff interviewed matches with roster. A resident roster dated for November 2022. All residents interviewed match with the roster. LPA reviewed R1’s physician report from August 2022 which indicates resident is bedridden. LPA reviewed a needs and services plan which shows resident needs support with some activities of daily living which resident confirmed they are receiving. Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.