Failure to Maintain Accurate Room Calendar and Information Board for Resident at Risk of Social Isolation
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services in a manner that enhanced a resident’s dignity and honored resident rights. Facility policy titled “Resident Rights and Facility Responsibilities,” revised September 3, 2020, states that the facility will comply with all resident rights and communicate these rights in a language residents and their representatives understand. For one resident with diagnoses including peripheral vascular disease and spinal stenosis, surveyors observed on March 9, 2026, that the dry-erase board in the resident’s room displayed the wrong month and year, indicating February 2026 when it was actually March 2026. Additionally, a wall calendar in the same room was left open to July 2025, rather than the current month. Review of the resident’s clinical record showed a care plan problem for psychosocial well-being, identifying the resident as at risk for social isolation related to admission to the facility, with an approach to provide an activity calendar initiated on July 31, 2025. The resident’s Quarterly MDS dated February 2, 2026, documented a BIMS score of 12, indicating the resident had some cognitive capacity for memory and orientation. During an interview, the Nursing Home Administrator stated that she would expect nursing or activities staff to update the dry-erase board and ensure the calendar displayed the correct month. The failure to maintain accurate date information and an up-to-date activity calendar in the resident’s room occurred despite the existing care plan and facility policy, resulting in a deficiency under 28 Pa. Code 211.12(d)(1)(5) related to nursing services and resident dignity.
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