Complaint·February 23, 2023

(Continue from LIC9099) R1 was observed attempting to get up but the gait belt restricted R1’s movements. It was further alleged that R1 was also observed laying in their hospital bed with large furniture items blocking their bed to prevent R1 from getting out of bed. On March 30, 2022, during a tour of the facility, R1 was observed sitting in their wheelchair with a gait belt wrapped around their body tied in the back. Review of R1’s medical records indicated that R1 had a diagnosis of dementia and required assistance with activities of daily living (ADLs), medication management and transfers. Review of records indicated that R1 was non-ambulatory based on both their physical and mental condition. R1 had a history of falls and fractures prior to moving into the facility. During the visit, R1 was observed to be appropriately dressed and groomed with no observable signs of neglect or physical abuse. During interviews, staff acknowledged that R1 was routinely restrained by a tied gait belt while sitting in their wheelchair in an attempt to prevent falls. R1’s medical records indicated that on March 22, 2022, a hospice physician order was put in place that indicated “facility may use a seat belt like devise tied loosely in the back of the wheelchair for safety with facility staff supervision as needed when the patient is up in their wheelchair”. However, Title 22 regulations require licensees to submit individual exception requests for Community Care Licensing (CCL) to review and approve the use of “postural support” devices, including gait and/or seat belts. Facility staff did not submit an exception request with supportive documentation to verify the physician’s order for R1. During interviews, staff indicated they were not aware that they were required to request approval and obtain advance authorization from CCL for the use of these types of devices. During the same visit conducted on March 30, 2022, another Resident (R2) [an LIC 811 Confidential Names List was provided to staff to identify the Resident (R2)] was observed lying in bed watching television. R2’s hospital bed was observed to be barricaded with large, heavy wooden chairs from where the half rails ended, up to the foot of the bed. (Continue at LIC9099C) (Continue from LIC9099C) During interviews, outside sources stated they consistently observed the chairs leaning against R2’s bed during regular visits. Outside sources stated they assumed it was standard protocol for facility staff to use the large chairs to block resident movement, as they had also observed another resident’s (R1’s) bed in the same manner. Staff admitted during interviews that the chairs were used as “block off” devices to prevent residents from falling out of bed. Staff explained they were not aware this practice was considered to be restraint, which is a personal rights violation. Record reviews determined no specific fall prevention measures, such as fall mats, tab alarms, increased monitoring or other allowable interventions were documented on R1 or R2’s needs and services care plans. The Department has investigated the allegation and has found that there was sufficient evidence to corroborate the allegation. Therefore, this allegation is deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A deficiency was cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D. A plan of corrections was developed with Administrator, Ray Cyrus Baha An exit interview was conducted with Administrator, Baha, to whom a copy of this report and Licensee Appeal Rights (9058 01/16) were provided at the conclusion of the visit.