Failure to Update Care Plans for In-Room Activities
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with severely impaired cognition and multiple mental health diagnoses. For one male resident with major depressive disorder, anxiety, lack of coordination, and moderate dementia, records showed that his care plan was not updated to reflect his current need for in-room activities, despite a documented decline in attending group activities. Although his name appeared on a list for in-room activities, there were no corresponding interventions in his care plan, and no revisions were made from June to September to address his changing activity preferences and needs. A female resident with unspecified dementia, generalized anxiety disorder, and cognitive communication deficits also had a care plan that did not accurately reflect her current activity needs. Her assessments indicated that activities such as keeping up with the news, being with groups, and going outside were important to her. However, her participation records showed she did not receive in-room activities for a three-week period, and her care plan interventions remained general, without specific updates to address her in-room activity needs. Interviews with facility staff, including the Activity Director, MDS Coordinator, and Administrator, confirmed that care plans were expected to be revised whenever there was a change in a resident's physical condition, cognition, or activity preferences. Despite this expectation and ongoing assessments, the care plans for these two residents were not updated to reflect their current needs for in-room activities, leaving staff without accurate guidance on how to meet their activity preferences.