Failure to Provide and Document Planned 1:1 Activities for a Bed-Bound Resident
Penalty
Summary
Facility staff failed to implement and document individualized 1:1 activity sessions as care planned for a cognitively intact, bed-bound resident with significant physical limitations and multiple medical conditions, including hemiplegia, osteomyelitis, a stage 4 sacral pressure ulcer, generalized muscle weakness, dysphagia, and malnutrition. The resident’s MDS showed dependence on staff for most ADLs, use of a wheelchair for mobility, and little interest or pleasure in activities. The care plan, revised on 03/05/2025, identified the resident as dependent on staff for activities, cognitive stimulation, and social interaction, with a goal for weekly participation in activities of choice. Interventions included inviting the resident to scheduled activities, providing 1:1 bedside or in-room activities if unable to attend group activities, providing an activities calendar and notifying the resident of changes, and having staff converse with the resident during care to encourage engagement. Surveyors’ review of activity task documentation from 02/05/2026 through 03/05/2026 showed only two documented 1:1 activity sessions, despite the care plan’s expectation for weekly participation. Progress notes from 02/02/2026 through 03/06/2026 contained limited entries from the activities department, such as brief social visits and mail delivery, and did not demonstrate consistent or structured 1:1 activity sessions as outlined in the care plan. Observations found the resident in bed or being transported for a medical appointment without signs of distress, and the activities calendar was posted on the wall behind the head of the bed. In an interview, the resident stated she was unaware the activities calendar was in her room, did not know the activities process, and learned of at least one event only when informed by a CNA. The Activities Director and DON both stated that residents with physical limitations who cannot attend group activities should receive weekly 1:1 or bedside activities and be reminded of activities, but the documented record did not show consistent provision or documentation of these 1:1 sessions for this resident.
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