Failure to Provide Ongoing Activities Meeting Psychosocial Needs
Penalty
Summary
A deficiency was identified when a resident with dementia, Alzheimer's disease, and major depressive disorder was not provided with an ongoing activity program that met her psychosocial needs for multiple periods. The resident's care plan specified the importance of activities such as reading, listening to music, being around animals, staying updated with the news, participating in group activities, going outdoors, and engaging in religious practices. The care plan also included goals for both in-room and out-of-room activities, with interventions to invite, encourage, and assist the resident in participating as tolerated. Observations over several days showed the resident lying in bed, unresponsive to greetings, with no music playing and the television turned off. There was no evidence of activities being provided in the resident's room during these times. The Activities Director confirmed that the resident did not receive any activities that met her psychosocial needs during two specific periods, and acknowledged that this lack of engagement would not maintain the resident's activity level as intended by the care plan. Interviews with facility staff, including the Activities Director and the DON, revealed that residents unable to attend group activities should be provided with bedside activities to keep them engaged. The DON stated that it was unacceptable for a resident to go without activities meeting psychosocial needs for several weeks, as this could lead to a decline in activity level and self-isolation. Review of the facility's policy confirmed the requirement to provide individualized, ongoing activity programs based on resident assessments and preferences, including special considerations for residents with dementia.
Plan Of Correction
Activities Meet Interest/Needs Each Resident How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #30 plan of care was updated to include alternate activities on 04/11/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Activities Director completed an audit on 04/17/2025 to ensure that residents have activities offered. All residents in the facility have the potential to be affected by this deficient practice. No other residents were identified. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was initiated by facility Administrator on 04/11/2025 to Activities Director regarding the importance of offering residents activities. e) DON and/or designee will conduct weekly random audits of residents' activities charting to ensure that residents are offered activities. Issues identified during these audits will be brought forth to the five-day a week clinical department manager meeting for review, validation, and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: f) DON and/or designee will conduct weekly random audits of residents' activities charting to ensure that residents are offered activities. Issues identified during these audits will be brought forth to the five-day a week clinical department manager meeting for review, validation, and immediate correction. All non-compliance issues identified will be corrected immediately and reported to the Administrator for review, validation, and resolution. DON will do trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendations. 04/17/2025