Failure to Provide Adequate Activities for Resident
Penalty
Summary
The facility failed to provide adequate activities for one of the sampled residents, Resident 24, outside of her room, leading to feelings of isolation and lack of socialization. Resident 24, who was admitted with conditions including hemiplegia, hemiparesis, and epilepsy, expressed a desire to participate in group activities and go outside for fresh air. Her Minimum Data Set (MDS) indicated that it was very important for her to engage in group activities and enjoy outdoor time when the weather permitted. Despite this, the resident reported that she only left her room when housekeeping performed deep cleaning, and the Activities Director (AD) confirmed that activities were primarily conducted one-on-one in her room. The AD noted that Resident 24 often declined invitations to join group activities, but the Director of Rehabilitation (DOR) acknowledged that the resident had expressed a desire to leave her room and the building. A custom wheelchair was ordered to facilitate her safe and comfortable participation in activities outside her room. The facility's policy on activities, revised in 2021, stated that the program should meet the needs, interests, and preferences of residents, which was not adequately fulfilled in this case, as Resident 24's care plan required a variety of activity types and locations to maintain her interests.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, Resident 24 was offered to attend group activities on the following day (3/6/25). On 3/6/25, Resident 24 attended group activities including but not limited to coffee chat, morning warm-up, daily chronicle, bowling, Soul Train, and a movie with popcorn. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/18/24, the Social Services Director (SSD) and Social Services Assistant (SSA) conducted resident interviews regarding group activity participation. Residents who verbalize a desire to participate in group activities responded to the survey that they do attend group activities. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/18/25, the Director of Nursing and Director of Staff Development (DSD) in-serviced the Activities Department and Certified Nursing Assistants on the facility's policy and procedure titled "Activities Program" with emphasis on the facility providing an activity program designed to meet the needs, interests, and preferences of the residents and ensuring residents who express the desire for a particular activity, for example, group activities, be assisted in participation. Department Managers will conduct room rounds daily for five days weekly for two weeks and monthly thereafter to ensure residents who have the desire to participate in group activities are assisted with attending group activities. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for assisting residents with participation in group activities for three months or until compliance is met. What systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/18/25, the Director of Nursing and Director of Staff Development (DSD) in-serviced the Activities Department and Certified Nursing Assistants on the facility's policy and procedure titled "Activities Program" with emphasis on the facility providing an activity program designed to meet the needs, interests, and preferences of the residents and ensuring residents who express the desire for a particular activity, for example, group activities, be assisted in participation. Department Managers will conduct room rounds daily for five days weekly for two weeks and monthly thereafter to ensure residents who have the desire to participate in group activities are assisted with attending group activities. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for assisting residents with participation in group activities for three months or until compliance is met.