Failure to Provide Adequate Activities for Resident
Penalty
Summary
The facility failed to provide adequate, ongoing activities designed to meet the needs of a resident, identified as Resident 9, as required by §483.24(c)(1). The facility's life enrichment programming policy mandates an ongoing resident-centered program based on comprehensive assessments and care plans, which should cater to the interests and abilities of each resident. However, for Resident 9, who has hemiplegia and dysphagia following a stroke, there was no documented evidence of participation or refusal of activities during several weeks across November 2024 to January 2025. Interviews revealed that Resident 9's spouse indicated the resident does not like to get out of bed and is not provided with in-room activities, leaving television as the only option. The Activities Director confirmed that Resident 9 was scheduled for weekly one-to-one bedside/in-room visits and activities, but there was no documentation to support that these activities occurred during the specified weeks. This lack of documentation and activity provision indicates a failure to meet the resident's needs as outlined in their care plan.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #9 activity preferences and care plan were updated. To identify other residents with the potential to be affected, the Life Enrichment Director/designee will complete 100% audit of all residents to identify those at risk and in need of a 1:1 visit. To prevent a future occurrence, Life Enrichment Director will create a separate calendar listing the residents who trigger for a 1:1 visit based on the observation completed. Life Enrichment Director/designee will educate Life Enrichment Staff on how this process designed will work moving forward within the department and facility. To monitor and maintain ongoing compliance, Life Enrichment Director/designee will monitor the monthly activity logs for residents with Care plans for 1 to 1 visit weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.