Failure to Provide and Document Individualized Activities for Dependent Residents
Penalty
Summary
The facility failed to provide individualized activity plans and to document activity refusals for two of three residents reviewed for activities. According to the facility's policy, activities should be available to all residents to support their physical, mental, and psychosocial well-being, with assessments conducted at admission to determine preferences, including cultural and spiritual interests. However, for one resident, the Minimum Data Set (MDS) did not show an assessment of activity preferences, and the care plan indicated a need for 1:1 room visits and staff escort to group activities. Despite this, multiple observations showed the resident lying in bed, with no music or television on, and no evidence of activities being provided. Staff interviews confirmed that the resident was dependent on staff for all mobility and care, enjoyed music, and should have been offered activities, but there was no documentation of activities being offered or refused. For the second resident, the MDS indicated complex medical conditions, including depression, and highlighted the importance of music, favorite activities, and religious services. The care plan noted impaired vision and the need for staff assistance to participate in activities. Observations revealed the resident was often awake in bed with no music or television on. The resident expressed a desire to attend activities such as listening to music, going outside, and attending church services but required staff assistance for mobility. Staff interviews indicated that the resident needed help to get out of bed and that activities staff did not consistently offer or document activities, including religious services and fresh air, as outlined in the care plan. The facility's failure to consistently offer and provide meaningful, individualized activities, as well as to document refusals, was confirmed through observation, record review, and staff interviews. Both residents were dependent on staff for mobility and care, and their preferences and needs were not met according to facility policy and care plans. There was a lack of documentation for activities offered or refused, and staff did not ensure that residents were provided with opportunities for engagement as required.