Failure to Complete and Implement Therapeutic Recreation Assessment
Penalty
Summary
The facility failed to ensure that a therapeutic recreation assessment was completed and documented in the electronic medical record (EMR) for a cognitively intact resident who expressed a strong preference for music and individual activities. The resident's initial Activity Interview indicated that listening to music was very important, but the corresponding Therapeutic Recreation/Life Enrichment Assessment in the EMR was left blank, with only a note stating information would be entered at a later date. Although a completed paper assessment was later produced, the resident's care plan lacked an activities section to inform staff of preferences and goals, and there was no evidence in the EMR that life enrichment activities were offered or provided. Observations over several days showed the resident sitting alone in a quiet room, asleep in a wheelchair, without any music, television, or other forms of stimulation. The resident reported having requested a radio from multiple staff members but never received one or any follow-up. The Director of Therapeutic Recreation confirmed that the assessment was incomplete in the EMR and that the care plan did not include an activities section, attributing the lapse to staffing shortages and division of responsibilities within the department. Facility policy required completion of the therapeutic recreation assessment within 14 days of admission and identified the activities department as integral to interdisciplinary care planning.