Failure to Maintain Accurate and Complete Activity Participation Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by accepted professional standards. Observations and record reviews revealed that the activity participation of these residents was not properly documented. For one resident with dementia and anxiety, care plans indicated the need for encouragement and assistance with activities such as music, pet therapy, and reading materials. However, during multiple observations, the resident was found alone in her room, unengaged, with no activity items, food, or drink available, and no evidence of participation in scheduled activities. Electronic records initially showed minimal activity participation, inconsistent with the care plan interventions. Another resident, also with dementia and additional diagnoses including severe protein calorie malnutrition and adjustment disorder, was observed repeatedly in her room, facing a blank wall, with no activity items or engagement. This resident expressed confusion and distress, and electronic records indicated no participation in activity programs over the previous 30 days. Staff interviews revealed that activity staff had limited training and were unable to visit all residents daily, despite care plans requiring staff assistance with activities and regular room visits for those unable to attend group programs. When questioned, the Activity Director initially stated that both residents attended daily activities, but upon review, could not explain the lack of documentation or reconcile it with direct observations of the residents in their rooms. Later, the activity participation records were updated to show daily attendance for both residents, but the Activity Director attributed this to "late entries" and could not explain discrepancies between the documentation and observed resident locations. This sequence of events demonstrates a failure to maintain accurate and timely records of resident activity participation, as required by professional standards.