Failure to Provide Consistent and Meaningful Activities for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide consistent and meaningful activities, ensure adequate staffing and staff engagement, and maintain accountability for the implementation of scheduled activities for a resident with severe cognitive impairment and major depressive disorder. Observations revealed that the resident spent significant time sitting in a chair without engagement, despite scheduled activities being posted. Activity staff were observed not interacting with residents, instead using personal phones or completing crafts alone. Scheduled activities, such as a balloon toss, did not occur as planned, as confirmed by both nursing and activity staff. Interviews with family members and staff indicated concerns about the lack of life enrichment and engagement for the resident, with staff reporting increased responsibility to provide interaction due to inconsistent activity staff presence. The Activities Director acknowledged challenges with staffing, training, and the need for more structured, sensory-based activities, but also noted that staff should not be on their phones and are expected to engage with residents during scheduled activities. These findings demonstrate a failure to implement and maintain a consistent and meaningful activities program for residents, particularly those with cognitive impairments.
Plan Of Correction
F679 – Activities Meet Needs/Interests of Each Resident Element #1: The Activity Director met with Resident #33 to assess personal preferences, interests, and participation barriers. The resident’s care plan was updated to include individualized activity interventions aligned with their preferences. The resident was also reintroduced to one-on-one and small group programming, and staff were assigned to ensure engagement during scheduled activities. Element #2: The Activity Director conducted an audit of all residents’ activity care plans and participation records to identify residents who have had limited engagement or inconsistencies in scheduled activities. Residents with low participation or dissatisfaction with current offerings were flagged for follow-up by the Activities Department. Element #3: The Administrator reviewed the policy on Activities and revised as necessary. Community staff were re-educated on the policy for Activities to include the importance of person-centered programming and timely execution of the daily activity schedule. Element #4: The Activity Director and/or designee will conduct weekly audits of scheduled activity implementation, participation logs, and resident feedback for 12 weeks. At least 5 residents will be randomly selected weekly to verify engagement and satisfaction. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025