Failure to Assess and Provide Activities to Meet Resident Needs
Penalty
Summary
The facility failed to comprehensively assess and provide for the activity preferences and needs of three residents with significant cognitive and behavioral impairments. For two residents, the Minimum Data Set (MDS) Section F, which addresses preferences for routine and activities, was not completed, and there was no evidence of further assessment or attempts to gather information from family members or significant others as required. For the third resident, while some activity preferences were documented on admission, there was no ongoing assessment or care plan in place to address these preferences. The care plans for the affected residents lacked specific details about the types of activities the residents were interested in, how these activities would be offered, or when they would occur. Observations and interviews revealed that residents on the secured unit, particularly those with severe cognitive impairment or behavioral issues, were not provided with a formal activity program tailored to their needs. Instead, staff primarily relied on passive activities such as watching television in common areas, and some residents were not engaged in any meaningful activities throughout the day. Activity logs were found to be inaccurate, with participation marked for days that had not yet occurred and for activities in which residents did not actually participate. Additionally, some residents had no documentation of activity participation at all. Staff interviews indicated a lack of knowledge about where to find information on residents' interests, and the Activities Director confirmed that no comprehensive assessment process was in place to identify or address activity preferences. The Activities Director also reported challenges in obtaining supplies for activities due to budget constraints and inconsistent approval of requested items. As a result, the activities calendar was kept vague, and planned activities were sometimes not carried out. The facility's policy required the interdisciplinary care team to evaluate residents' personal history and preferences, but this was not consistently implemented for the residents reviewed.