complaint·September 22, 2023

Many of the residents said they used their bed rail as an assistive support mechanism to reposition themselves or to raise themselves from their bed. No resident or outside sources had concerns with the staff “restraining” residents with their bed rails. Review of records revealed that all 17 residents had approved orders by their physician or hospice agency for half-bed rails, as required by regulations. On September 18, 2023, LPA initiated the complaint investigation and observed that residents had half-bed rails secured to their beds as instructed by a physician. No residents’ bed rails were used as a restrictive device or restraint. LPA observed that residents used the bed rails to reposition themselves or to get out of bed. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during resident and outside source interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director Michael Sokolowski. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the receipt of these documents.