Failure to Assess and Document Resident Activity Participation
Penalty
Summary
The facility failed to properly assess and monitor the activities program for one resident with multiple diagnoses, including chronic obstructive pulmonary disease, above-knee amputation, depression, and anxiety disorder. The resident was cognitively intact and had an activities care plan that included providing leisure supplies, introducing the resident to others with similar interests, modifying schedules as needed, offering a variety of activities, and reassessing preferences. However, documentation of the resident's participation in activities was lacking, with task sheets for various activities showing no entries for the past thirty days, and activity tracking only indicating limited participation in movies/TV and occasional group activities. Interviews with the Activities Manager revealed that she was unaware of the requirement to document each resident's participation in activities and that the documentation system had only recently become operational. The Activities Manager admitted to not having documentation for any residents and relied on memory to complete activity records retroactively. The activities list provided only showed aggregate attendance numbers without identifying individual residents, making it impossible to monitor or evaluate specific residents' engagement or changes in participation. Further interviews with facility leadership confirmed that there was an expectation for the Activities Manager to track and review individual resident participation in activities, as this information is necessary to identify trends or concerns such as depression. The resident in question expressed interest in attending group activities depending on the type but was unaware of the current activity offerings, and no activity calendar was present in the resident's room. The facility's policy required monitoring and evaluating residents' responses to activities and revising approaches as appropriate, which was not followed in this case.