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32 | Regarding the allegation, “Staff restrict resident's mobility at the facility,” the Reporting Party (RP) expressed concern that Resident 1 (R1) was not permitted to move freely within the care facility. During an interview with Administrator Roberto Dela Vega Ramirez, they explained that the believes the situation stemmed from a misunderstanding regarding a bed rail. The administrator admitted that a full bed rail was utilized for R1 because R1 was restless and considered a high fall risk, though R1 was not on hospice care. He noted that an outside visitor subsequently advised him that a full bed rail constitutes a form of physical restraint. A review of R1's facility file confirmed there was a physician's order for a full bed rail due to a history of multiple falls out of bed; however, the resident was not under hospice services. Additionally, the administrator stated that when R1’s family requested physical or occupational therapy services, he informed them that therapy must be provided externally by Kaiser or other outside agencies. Additionally, during a phone interview with a former staff revealed that they were not allowed to do exercises with R1 and R1 was always in bed and they just repositioned R1 every 2 hours. Because the facility actively utilized a full bed rail, which can serve as a physical restraint restricting voluntary mobility on a non-hospice resident, the evidence confirms a regulatory violation occurred. Therefore, based on the information obtained, the allegation is deemed Substantiated at this time.
Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC9099-D). A copy of this report and appeal rights was provided.
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