Failure to Provide Individualized Activities Based on Assessment and Preferences
Penalty
Summary
The facility failed to provide individualized activities for one resident, as required by assessment and care plan, based on the resident's preferences and needs. The resident, who was admitted with diagnoses including pneumonia, weakness, and difficulty walking, was observed lying in bed awake and alert on multiple occasions, with no TV or music playing and no evidence of engagement in any activities. The resident was unable to speak but responded to greetings with a smile. Staff interviews revealed that in-room visits were conducted, but the Activity Director could not specify what activities were provided and acknowledged that activities were anticipated rather than planned according to an individualized assessment. A review of the resident's records showed no activity care plan or individualized activity assessment was present at the time of the observations. The MDS assessment did not document the resident's choices or preferences for activities. The Activity Director admitted that the assessment and care plan had not been completed within the required timeframe and that follow-up with the resident's family regarding preferences had not occurred as needed. Facility policy requires individualized activities and care plans to be developed based on assessment, but this was not done for the resident in question.