| 6400.32(r)(4) | On 5/20/2026 at 12:08pm, Individual #1's bedroom door was equipped with a straightedge locking mechanism. Staff and Individual #1 did not have the designated straightedge to unlock the mechanism to provide easy and immediate access to the room in the event of an emergency.
On 5/20/2026 at 12:11pm, Individual #2's bedroom door was equipped with a straightedge locking mechanism. Staff and Individual #2 did not have the designated straightedge to unlock the mechanism to provide easy and immediate access to the room in the event of an emergency.
On 5/20/2026 at 12:15pm, Individual #3's bedroom door was equipped with a straightedge locking mechanism. Staff and Individual #3 did not have the designated straightedge to unlock the mechanism to provide easy and immediate access to the room in the event of an emergency.
On 5/20/2026 at 12:16pm, Individual #4's bedroom door was equipped with a straightedge locking mechanism. Staff and Individual #4 did not have the designated straightedge to unlock the mechanism to provide easy and immediate access to the room in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | Program Director or designee to meet with all individuals who reside in the home and complete updated door lock forms. Door knobs will then be assessed to ensure that the accurate locking mechanisms are in place. For those who report they would like a lock on their door a knob will be installed with a unique key to that knob and the individual and staff will have corresponding keys. For those who decline to have a lock on their door a passage knob will be installed. To be completed by 7/1/2026. Requests to ISP's will be made if needed. |
07/01/2026
| Implemented |
| 6400.207(5)(II) | On 5/20/2026 at 12:15pm, Individual #3's bed contained full bilateral bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription on 3/24/2026, indicating that the bedrails are to prevent falls and achieve functional body positioning due to the individual's diagnoses of generalized weakness and gait instability. Although the bed rails are prescribed by the medical practitioner, Individual #3's support plan, last updated 11/5/2025, did not include periodic relief of the device to allow freedom of movement. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Balance or support to achieve functional body position, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | The Program Specialist or designee will send ISP change form by 6/15/2025 indicating that individuals #3 is able to verbally request period relief of the bilateral bed rails to allow freedom of movement. |
06/15/2026
| Implemented |