Failure to Develop Person-Centered Activities Care Plan for Cognitively Impaired Resident
Penalty
Summary
The facility failed to develop a person-centered activities care plan for a resident who was severely cognitively impaired. The resident was admitted to the facility and, according to the Admission Medicare - 5 Day Minimum Data Set assessment, was documented as severely cognitively impaired. A review of the resident's electronic health record (EHR) revealed there was no care plan addressing activity preferences, goals, or interventions. Multiple observations over several days showed the resident lying in bed, either sleeping or awake, with no evidence of engagement in activities. Interviews with staff indicated that the resident enjoyed singing, morning exercises, and watching TV in her room, but there was no care plan in place to support these preferences. Staff members acknowledged the absence of an activities care plan and noted that the resident did not participate in many activities, often remaining in bed. The resident herself expressed a desire to participate in activities but stated she only got out of bed sometimes. Staff also indicated that the resident might participate if encouraged to get out of bed, but no structured plan was documented to facilitate this.