Deficiencies in Resident Activities and Safety Signage
Penalty
Summary
The facility failed to provide adequate and appropriate health care by not assisting and providing activities per preference to a resident. The resident expressed a willingness to participate in activities but was not informed or invited by the staff. Observations revealed that the activity calendar was placed too high for the resident to see, and there was a lack of documentation regarding the resident's participation in activities. The resident's care plan indicated a need for encouragement and assistance to attend activities, but these interventions were not effectively implemented. Additionally, the facility failed to coordinate communication with a center for another resident. There was a lack of documented evidence of collaboration of care and communication between the nursing facility and the unit. This included participation in care conferences and the review of control policies and procedures, which are essential for ensuring comprehensive care for the resident. Furthermore, the facility did not ensure appropriate cautionary and safety signs were posted in 23 randomly observed rooms where certain procedures were administered. Despite having no smoking signs outside the facility, there were no specific signs indicating the use of certain procedures inside the facility. The facility lacked a policy related to the posting of these signs, which is necessary for maintaining safety standards.
Plan Of Correction
Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the provider of the truth of the items alleged or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by the provision of Federal and State Laws, code section 1280 and 42 CFR 483.1. 1. Resident #71 has been discharged from the facility. Resident #36 has been discharged from the facility. Signage was updated to reflect use inside the facility. 2. Activities Director/Designee has completed a review of current facility residents to confirm that activities are provided per preference. Director of Nursing/Designee has conducted a review of current facility residents to verify communication is completed as required. Follow up based on findings. Administrator/Designee completed observation of facility entrances to verify signage stating usage is present. 3. Staff Development Coordinator/Designee has provided education to activity staff related to assisting and providing resident's preferred activities. Staff Development Coordinator/Designee has completed education for current facility licensed nurses related to communication requirements. Regional Support Team member provided education for the facility Inter Disciplinary Team related to signage posting requirements. 4. Activities Director/Designee to monitor residents to verify that activities are provided per preference using a random sample of 10 residents weekly x 3 months then as needed until substantial compliance is achieved. Director of Nursing/Staff Development Coordinator/Unit Manager/Designee to complete monitoring of residents to verify communication documentation is present weekly x 3 months, then as needed until substantial compliance is achieved. Administrator/Designee observed the facility entrances to verify in use signage in place weekly x 4, then as needed until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.