complaint·September 19, 2023

only ordered once requested by the POA and not automatically given to the resident as a part of their durable medical equipment. R1’s POA signed for bed rails on 9/1/2023. Bed rails were delivered later that day. Per the signed bed rail consent, “bedrails are considered a restraint and bring with them the risk of injury and death . . . Hospice encourages families/caregivers to consider alternative options in place of bedrails to help ensure the safety of patients.” LPA reviewed R1’s medication list. There were no antibiotics ordered for R1. Per interviews with staff, R1’s POA declined an antibiotic when R1 was in the hospital. Therefore, the facility did not receive this order. Additionally, interviews with staff acknowledged that at R1’s end of stay at the facility, they needed encouragement to eat with meals. Staff stated that R1 was offered 3 meals per day, including liquids. Per interviews, R1 had the right to refuse, but they were still offering meals and assistance with feeding. LPA interviewed staff who stated that there were never any witnessed accounts or reports of staff being rough with R1. Although R1 had a history of behaviors, staff stated that R1 was usually able to be redirected. Interviews with management stated that there were no reports to them about rough staff. Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of this report was left at the facility.