Failure to Develop and Implement Activity Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for one resident regarding her activities. During an observation and interview, the resident was found to be alert, oriented, and actively participating in a resident council meeting, and she identified herself as the current resident council president who regularly attends meetings. Review of her admission record showed she was readmitted with a primary diagnosis of idiopathic peripheral autonomic neuropathy, and her order summary allowed participation in activities as long as they did not conflict with her treatment plan. Despite these findings, a review of her care plans revealed that there was no activity care plan in place for her, nor were there any documented interventions or updates regarding the effectiveness of her current activities. Both the director of activities and the DON confirmed that the resident did not have an activity care plan, which was inconsistent with the facility's policy requiring comprehensive, person-centered care plans with measurable objectives and timetables for each resident.