Failure to Provide Meaningful and Individualized Activities
Penalty
Summary
The facility failed to provide meaningful activities tailored to the interests and needs of a resident with a diagnosis of depression, as required by their care plan and comprehensive assessment. The resident, who was cognitively intact and expressed a strong preference for choosing her own bedtime, being around pets, and participating in favorite activities, reported that the facility did not support her involvement in activities of interest. Observations showed the resident often remained in her room, and interviews revealed she felt the activities program did not meet her needs, particularly due to the lack of evening activities, pet therapy, and opportunities to serve others or participate in community outings. Review of activity calendars and participation records confirmed that group activities were only offered during daytime hours, with no evening activities, pet therapy, or community outings available. The activity program did not include activities that allowed residents to serve others or gain a sense of purpose, and the last such activity was a one-time event several months prior. The resident described the available group activities as unfulfilling and childish, and expressed feelings of boredom, lack of purpose, and disconnection from the community. Interviews with facility leadership revealed that resident activity needs were assessed primarily through MDS assessments, and there had been no recent assessment of the need for evening activities. The facility had not provided community outings in years and relied on family or friends for residents' participation in community-based leisure. The activity director was unaware of the need for evening activities and did not routinely review activity assessments, resulting in a lack of individualized programming to meet the diverse needs and preferences of residents.
Plan Of Correction
1. Activities staff visited with the resident to update the resident's needs and preferences, and encouraged the resident to express wishes for activities. The resident provided ideas and suggestions that will be implemented. 2. All residents who would like help to plan or participate in activities have the potential to be impacted. 3. The facility reviewed the Patient Activities Assessment policy, assessment tools, and documentation tools, and determined they are appropriate to capture individual resident preferences and participation. The facility reviewed the policy Patient Activities Program and added a quality assurance process to ensure the program meets the needs of the resident population. Beginning July 2025, the activities calendar will include evening activities and opportunities to serve others. Seasonal outings will begin in August. The activities department will audit resident participation monthly to ensure group activities are well attended. At least monthly, the activities department will ask residents to evaluate a group activity for opportunities to improve or replace it. Education will be provided to all employees about the right to participate in activities that meet the interests and needs of each resident and how the facility supports these activity pursuits through group and individual programs. The resident council will also receive this education in the July meeting. 4. The activities department will interview five residents monthly to ensure each individual resident is offered activities that are meaningful to them personally, for at least the next 12 weeks. 5. The Executive Director is responsible for compliance.