Failure to Provide Meaningful Activities for a Resident
Penalty
Summary
The facility failed to ensure the provision of meaningful activities for a resident, leading to a deficiency in supporting the resident's physical, mental, and psychosocial well-being. The facility's policy required the Department of Recreational Therapy to provide leisure programs for all residents, including those unable to attend group activities, on a seven-day-per-week basis. However, Resident #10, who was admitted with a diagnosis that included an inability to complete a mental status interview, was observed over several days in bed, non-verbal, and not participating in any activities. The resident was noted to be in the same position with the lights and television off, indicating a lack of engagement in meaningful activities. Interviews with the Activities Director revealed that although the resident was assessed for activity preferences upon admission, there was no documentation of one-on-one activity visits for the resident. The Activities Director acknowledged that one-on-one visits were not documented, which was a deviation from the facility's policy. The Director of Nursing confirmed the lack of documentation for one-on-one activities, which contributed to the deficiency in providing adequate support for the resident's quality of life.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 Corrective Action for those identified: A progress note regarding the programming offered/implemented was completed on 2/13/25. The resident #10 passed away prior to receiving the statement of deficiencies. Identification of other residents and corrective action: All residents have the potential to be affected by the deficient practice. An audit of all recreation care plans for appropriate goals/interventions and appropriate documentation will be completed and any gaps identified will be addressed. Measures and Systemic Changes: Implemented policy “Recreation Program Development” 3/10/2025. Updated the Recreation Attendance sheet to include the time of a 1 on 1 visit. Education of the Recreation staff related to the new policy and documentation will be completed by 3/31/25. Monitoring: A weekly review of residents with a change in condition/status will be completed x30 days and as changes occur. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Erin Fazzio, Supervisor of Recreation, by 3/31.