Failure to Provide Resident-Centered Activities Program
Penalty
Summary
The facility failed to provide an ongoing activities program tailored to the preferences of a resident, identified as Resident #12. The resident's clinical record lacked a written activities care plan, despite the resident expressing preferences for certain activities such as going outside for fresh air and participating in religious services. The resident reported feeling lonely and mentioned that her workbook was lost during a room transfer, which the facility staff could not locate. The Activities Director (AD) admitted to not documenting one-on-one activities or visits, and although the AD claimed to engage with the resident, there was no written evidence to support these interactions. Interviews with the resident and the AD revealed inconsistencies in the activities provided. The AD stated that she conducted one-on-one room visits and offered activities like makeup sessions and reading, but the resident contradicted this by stating that her makeup was only done once. The AD also mentioned that the resident received visits from church friends and was brought to music events, but did not provide magazines or other requested items because the resident had not explicitly asked for them. The lack of documentation and a formal care plan for activities was acknowledged by the facility's Administrator, who noted that if it is not documented, it is considered not done.
Plan Of Correction
F679 ACTIVITIES MEETS INTEREST/NEEDS EACH RESIDENT 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of resident #12, and 1 on 1 activities in room visits not being documented. The Activities Director will be in-serviced about activities 1 on 1 room visits and proper documentation of the visits. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Activities Director will be in-serviced about activities 1 on 1 room visits and proper documentation of the visits. Random QA audits will be conducted by the Administrator or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Administrator or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Administrator a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date: