Failure to Accurately Assess and Document Resident Activity Preferences
Penalty
Summary
The facility failed to ensure that the Activities Director accurately completed, directed, or delegated the accurate completion of the activities component of the comprehensive assessment for residents, particularly those with severe cognitive impairment. Review of facility documents, clinical records, and staff interviews revealed that for 28 residents with severe cognitive impairment, there was no attempt to obtain information on resident preferences from family, significant others, or staff interviews, as required when residents are unable to communicate their preferences directly. Instead, the assessments consistently documented that all activity preference questions were answered as 'Very Important' and that this information was obtained from the resident, even when the resident's cognitive status indicated they were unable to reliably communicate such preferences. Analysis of the Minimum Data Set (MDS) comprehensive assessments showed a pattern of uniform responses. Of the 100 assessments reviewed, 66 were completed by the Activities Director, with 92.4% of these having all answers marked as 'Very Important.' Similar patterns were observed in assessments completed by other staff, with a high percentage of uniform responses and little variation, regardless of the resident's cognitive ability. In several cases, residents had BIMS scores indicating severe cognitive impairment or were rarely understood, yet the documentation still reflected that all preferences were obtained directly from the resident and marked as 'Very Important.' Interviews with the Activities Director confirmed responsibility for completing the activities component of the MDS and acknowledged the uniformity of responses, attributing it to the answers provided during interviews. However, there was no evidence that alternative sources, such as family or staff, were consulted for residents unable to communicate their preferences. The deficiency was communicated to the Nursing Home Administrator, highlighting the facility's failure to follow required procedures for accurately assessing and documenting resident activity preferences, especially for those with severe cognitive impairment.