Failure to Develop and Implement Comprehensive Activity Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing the activity preferences and needs of a resident with multiple complex medical diagnoses, including neurocognitive disorder, depression, and chronic pain. The resident, who had moderate cognitive impairment, reported feeling bored and was unaware of any activity calendar or invitations to participate in facility activities. Observations confirmed that no activity calendar was posted in the resident's room during initial visits, and the medical record lacked documentation of a care plan for activity preferences, despite the Life Enrichment Assessment indicating that functional status related to activities should be addressed in the care plan. Interviews with facility staff, including the Nursing Home Administrator and Activity Assistant, revealed that it was expected for all residents to have documented activity preferences in their care plans and to receive an activity calendar. However, the resident's records did not reflect these practices, and activity participation documentation showed mostly solitary activities, with limited staff involvement and no evidence of group activities being offered. The deficiency was identified through observation, interview, and record review, highlighting the facility's failure to ensure a comprehensive, individualized care plan for the resident's activity needs.