Failure to Conduct Activity Assessments and Provide Activities
Penalty
Summary
The facility failed to carry out activities according to a resident's care plan and did not conduct ongoing activity assessments for residents. Specifically, Resident #25 was observed multiple times without the daily newspaper in their preferred language, which was part of their care plan. The Activities Director (AD) was unaware of who was responsible for providing the newspaper and admitted to a lack of documentation regarding Resident #25's participation in activities. The AD also mentioned that activity assessments should be conducted quarterly, but there was no evidence of this being done. Additionally, the facility did not have updated activity assessments or participation documentation for several residents, including Residents #3, #21, #25, #83, and #84. For instance, Resident #3's last documented activity assessment was from 2022, and there were no participation logs available. Resident #21 had no activity assessments or documentation, and Resident #83's assessment was incomplete and not entered into the electronic medical record (EMR). Resident #84 also lacked activity assessments and participation documentation. The facility was unable to provide any documentation confirming residents' participation in activities. The surveyor requested the facility's policy on activities but only received a job description for the Recreation Director, which outlined responsibilities such as coordinating and documenting assessments and designing a comprehensive activity program. The facility administration had no additional information to offer when these concerns were discussed.
Plan Of Correction
1: The facility implemented a recreation attendance record for the 7 residents identified. All care plans for the 7 residents identified were updated appropriately. 2: All residents had the potential to be affected by the deficient practice so the facility implemented a recreation attendance record for all other residents as well. 3: The care plans for all current residents were reviewed and updated as needed. The Activities director and staff were educated on proper care planning of activity preferences as well as the recreation attendance record policy/process. 4: The Administrator/designee will audit 5 care plans weekly x4 to ensure they reflect activity preferences that were identified in the assessment. The administrator/designee will also audit 10 resident attendance records weekly x4 then monthly x2 ensuring proper compliance. Results will be reported to the QAPI committee for review and action as necessary. 5: 3-3-2025 Element One Corrective Actions: A Certified Activities Director reviewed, revised as appropriate, and signed the activity participation review (APR) for Resident #1. The care plan was also reviewed and updated as needed to reflect the current interests, abilities, and preferences. A Certified Activities Director reviewed, revised as appropriate, and signed the activity participation review (APR) for Resident #6. The care plan was also reviewed and updated as needed to reflect the current interests, abilities, and preferences of Resident #6 and activity staff were re-educated about the changes. A Certified Activities Director reviewed, revised as appropriate, and signed the activity participation review (APR) for Resident #7. The care plan was also reviewed and updated as needed to reflect the current interests, abilities, and preferences of Resident #7 and activity staff were re-educated about the changes. The facility implemented a recreation attendance record to be completed each day to reflect attendance at group activities. In-room visits are documented on the same form noting date and Resident. Element Two Identification of At-Risk Residents: All residents had the potential to be affected by the practice. Element Three Systemic Change: An audit of the most recent APR for current Residents was completed by Certified Activity Directors and changes made as appropriate to reflect the current interests, abilities, and preferences of each Resident. The care plan of each Resident was reviewed and updated as appropriate based on the APR and activity staff educated about any changes. Activities staff were re-educated about the recreation attendance record to be completed daily that reflects attendance at group programs and in-room visits. A Certified Activity Director (CAD) was hired and started on March 3, 2025. The new CAD is being mentored by sister facility CADs as needed. Element Four - QAPI: The Activity Director/designee will audit resident group attendance and in-room visit records weekly x4 then monthly x2 ensuring proper compliance. Results will be reported to the QAPI committee for review and action as necessary. Completion Date: 3-5-2025