SANTA MONICA, CA - Ocean Park Healthcare was cited for multiple violations involving improper use of restraint devices without required physician orders or informed consent during a May 4, 2025 inspection.
Restraints Used Without Physician Orders
Inspectors documented two residents subjected to restraint devices without proper authorization. Resident 10, who had encephalopathy, chronic obstructive pulmonary disease, and dementia, was observed with bed siderails raised and confined to a geri-chair with lap tray despite lacking physician orders for these restraints.
The facility's records showed no physician order for bed siderails as of May 4, 2025, and no informed consent documentation for either the bed rails or geri-chair with lap tray. Additionally, no care plan existed addressing the use of bed siderails.
During observations over multiple days, Resident 10 was repeatedly seen sitting alone in a geri-chair with lap tray in the hallway, appearing confused and speaking incoherently. On one occasion, the resident's right leg was dangling from the side of the chair with no staff assistance present.
Staff Acknowledge Improper Practices
When confronted with these observations, facility nursing staff acknowledged the violations. Registered Nurse Supervisor 1 stated during the inspection that "there should be an order and a Care Plan for the use of bed siderails" and confirmed that "an informed consent must be obtained from the resident and/or resident's representative for any device used that may restrict resident's mobility."
The Director of Nursing admitted the facility was not properly documenting restraint use, stating the "assessment for Physical Restraint was not properly documented" and acknowledging that "the use of these devices restricts resident's movement."
Geri-Chair Positioned as Restraint
A second resident, Resident 3 with Parkinson's disease and mobility issues, was found to have a geri-chair positioned alongside their bed in a manner that constituted an improper restraint. Staff recognized this placement created safety hazards and restricted access.
Certified Nursing Assistant 3 told inspectors that "the geri chair should not be placed alongside the bed of Resident 3 for safety reasons" because "the geri chair at the bedside may lead to Resident 3 bumping into the chair, trip, fall, it is dangerous."
The nursing supervisor confirmed this positioning functioned as a restraint, stating the resident "may not be able to get out of bed, their access may be blocked and get the resident entrapped or trapped."
Medical Implications of Improper Restraint Use
The unauthorized use of restraint devices poses significant risks to nursing home residents. Bed rails can cause entrapment injuries, falls, and increased agitation in residents with dementia. Geri-chairs with lap trays, when used improperly, can restrict circulation, cause pressure sores, and lead to muscle atrophy from prolonged immobilization.
For residents with cognitive impairment like dementia, restraints often increase confusion and distress rather than providing safety benefits. Research demonstrates that restraint use frequently leads to more falls, not fewer, as residents attempt to escape from the devices.
The facility's own assessment noted Resident 10 had "poor safety awareness/judgment" and "inability to consider lack of independence, disorientation and impaired cognition." However, these conditions require individualized interventions and alternatives to restraints, not unauthorized confinement.
Regulatory Requirements Violated
Federal regulations require specific protocols for any restraint use in nursing facilities. These include obtaining a physician's order specifying the medical reason, duration, and type of restraint. Informed consent must be secured from the resident or their representative, and care plans must address the restraint use with regular monitoring.
The facility's own policy, revised in August 2024, clearly states that "restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative." The policy specifies that orders must include the specific medical reason, how the restraint benefits the resident's condition, and the type and duration of use.
The policy also defines practices that constitute improper restraint use, including "using bedrails to keep a resident from voluntarily getting out of bed" and "placing a resident in a chair that prevents the resident from rising."
Additional Notification Violations
The inspection also revealed failures in required discharge notifications. For Resident 39, who was discharged to an assisted living facility in February 2025, the facility failed to provide timely notification to the State Long-Term Care Ombudsman as required by policy.
The notification was not sent until May 4, 2025 - nearly three months after the discharge occurred. The Director of Nursing initially claimed they had 30 days to notify the Ombudsman after discharge, but later acknowledged that policy requires 30-day advance notice before discharge to allow the Ombudsman to assist residents who may disagree with discharge plans.
Assessment Accuracy Concerns
Inspectors also identified issues with assessment accuracy that could affect care planning and service delivery. The facility failed to ensure proper assessment entries for at least one resident, though specific details were redacted from the public report.
Accurate assessments are fundamental to developing appropriate care plans and ensuring residents receive services matching their needs and conditions.
Industry Standards for Restraint Alternatives
Current best practices in nursing home care emphasize restraint-free environments whenever possible. Alternative approaches include increased supervision, environmental modifications, addressing underlying medical conditions causing agitation, and providing meaningful activities.
For residents with dementia and mobility issues like those at Ocean Park Healthcare, appropriate interventions might include lowering bed heights, using floor mats instead of bed rails, providing comfortable seating with easy exit access, and ensuring adequate staffing for supervision and assistance.
Physical and occupational therapy evaluations can identify specific interventions to improve safety and mobility without restricting movement. Regular medication reviews may identify drugs contributing to confusion or fall risk that could be adjusted.
Facility Response Required
Ocean Park Healthcare must develop corrective action plans addressing these violations and demonstrate compliance with federal restraint regulations. This includes implementing systems to ensure physician orders and informed consent are obtained before any restraint use, training staff on proper restraint policies, and establishing monitoring procedures to prevent unauthorized restraint applications.
The facility must also correct its discharge notification procedures to ensure the State Long-Term Care Ombudsman receives required advance notice of all planned transfers or discharges.
These violations highlight the importance of resident rights protections in nursing facilities and the need for proper oversight of practices affecting resident mobility and autonomy.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Santa Monica Conv Ctr I from 2025-05-04 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.