complaint·April 16, 2024

(R1) was newly diagnosed with Parkinson disease on March 20, 2024. Personal service plan dated October 05, 2023, page 4 indicates R1 ambulates with a rolling walker independently throughout the community, although R1 prefers to stay in their room or in bed most of the time. R1 has episodes of dizziness and anxiety that causes R1 to have tremors and is prone to bedsides and bathroom falls. Staff to remind R1 to use call light pendent, request and wait for staff assistance when feeling anxious or dizzy. Staff to observe environment when assisting with meds, care and remove hazards. Remind R1 to wear non-skid sole slippers/shoes while ambulating. Communicate with primary care physician regarding falls and residents’ safety. Unusual incident/injury reports submitted to the Department reflect that facility has called 911 immediately upon R1 having falls. Report also indicate that R1 has had subsequent non-injury falls due to non-compliance with use of assistive device despite staff re-orientation and reminder to use walker. Reports indicate that on March 20, 2024 R1 was admitted to hospice care and service plan to be updated and reflect current needs. Tour of R1’s bedroom LPA observed a rollator walker with seat in the bathroom. Interviews with 4 of 4 staff indicate that the facility since resident had more fall implemented safety checks about two times every hour. Staff indicated that R1 does not like carrying pendent, forgets it or simply refuses to use it. Staff indicated that R1 must be reminded to use the walker even on short distance walks. Staff constantly remind R1 the importance of the pendent and to wear it as well as the importance of using the walker for ambulation assistance. R1 has always been very independent but facility has been proactive on implanting stand assist for R1 as needed and when requested. Staff indicated that they encourage proper use of assistive devices and additional personalization for falls management based on R1’s history and diagnosis while balancing independence, dignity, and choice. Based on the information gathered during the investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. This report was reviewed with Executive Director and a copy was furnished to the facility.