Failure to Include Resident Activity Preferences in Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to address a resident's preferred activities. The resident, who was dependent on a ventilator due to chronic respiratory failure and had severely impaired cognition, required total assistance with activities of daily living. The resident's activity assessment documented preferences for soft music, western, and reading tapes, and the Activity Director confirmed that these activities were provided during room visits. However, a review of the resident's care plan revealed that it did not include the resident's stated activity preferences. The Activity Director acknowledged during an interview that the care plan should have been updated to reflect these preferences. The facility's policy requires that each resident have a comprehensive care plan that includes goals and measurable objectives to meet their medical, nursing, mental, and psychosocial needs, as identified during assessment, but this was not followed in this case.