Failure to Complete Activity Evaluations and Document Resident Participation
Penalty
Summary
The facility failed to develop, implement, and provide appropriate oversight of the activities program to support residents' choices and needs. Specifically, activity admission evaluations were not completed according to the facility's established policy for several newly admitted residents. In some cases, the required Activity - admission Evaluation forms were missing from the medical records, and in one instance, the form was present but left completely blank. The information regarding residents' activity preferences was primarily documented in the Minimum Data Set (MDS) rather than in the designated forms within the medical record, making it inaccessible to CNAs and LNs responsible for implementing activity choices. Oversight of the activities program was lacking, as the Activities Supervisor did not actively oversee the program for the facility, instead focusing on another LTC facility on the same property. The monthly activity calendar was created and implemented by Activities Staff, despite this not being within their job description, and the calendar had not been updated since a change in facility ownership. The Activities Supervisor's job description required planning, developing, organizing, implementing, and directing the activities program, but these responsibilities were not being fulfilled as intended. Additionally, the facility did not have a method to document specific resident participation in each activity offered. The electronic medical record's Point of Care (POC) charting section only allowed for a general, once-daily notation of activity participation by category, without specifying which activities a resident attended. This lack of detailed documentation prevented evaluation of the effectiveness of the activities program and whether it met residents' assessed needs and preferences.