Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of three residents. These residents were not provided with activities that aligned with their preferences, specifically the ability to watch television in their rooms. The facility's policy required the Activity Leader to record the recreational interests and needs of each resident upon admission, and the Activity Director was responsible for planning a varied program of activities to meet these needs. However, this was not implemented effectively for the residents in question. Resident #219, diagnosed with Alzheimer's disease and other conditions, expressed a desire to watch television in their room, a preference that was not met due to the removal of the television set for maintenance. Despite being cognitively intact and having no vision or hearing problems, Resident #219 was left without their preferred activity for several weeks. The Comprehensive Care Plan and Activities Evaluation both documented the importance of keeping up with the news and engaging in favorite activities, yet no alternative activities were provided. Similarly, Resident #237, with diagnoses including dementia and anxiety disorder, and Resident #436, with dementia and muscle weakness, were also left without their preferred activity of watching television. Both residents had tablets in their rooms, but they did not know how to use them. The facility's staff, including the Activities Director and the Director of Maintenance, acknowledged the issue but failed to resolve it promptly. The delay in reinstalling the television sets was attributed to the need for new equipment, but no interim solutions were provided to ensure the residents' activity preferences were met.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1: F679 Corrective Actions for Residents Identified Interest and activity preferences of residents #219, #237, and #436 were reviewed. Televisions were immediately installed inside the rooms of the identified residents. Care Plans were updated, reflecting changes in interests or abilities. Element 2: Residents at Risk All residents have the potential to be affected by this practice. The activities department audited to ensure all resident assessments and activities of choice were accurately provided based on their documented interest and needs. There were no more issues identified. An audit tool was developed to monitor compliance. Element 3: Systemic Changes Policies and Procedures Regarding Resident Preferences and Activity Planning were reviewed; no revisions were required. Activity staff is being trained on the importance of individualized activities and how to incorporate them into daily care. Education will be provided on creative engagement techniques for residents with dementia or sensory impairments. In-service on effective communication between activity staff, CNA, LPNs, and RN's, Social Service, and Rehab to ensure seamless integration of activities into daily routines. Tools such as Questionnaires and resident Council Meetings will gather feedback and suggestions, which will be used to refine the activity program continuously. Any outstanding findings will be immediately corrected and reported to the administrator. Element 4: Monitoring of Corrective Actions The Activities Director will conduct weekly checks for 90 days and monitor residents' participation and satisfaction with activities. Five to seven residents will be randomly selected to ensure that provided programs support their choice of activities. On a monthly basis, the Activities Director will submit findings to the administrator. The Activity Director will report findings to the QAPI Committee quarterly for 3 quarters. The QAPI Committee will determine if further action is required. Element 5: Date of completion: (MONTH) 12, 2025 Person Responsible: Activity Director.