|§483.24(c) Activities. |
§483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide an ongoing program of activities designed to meet the interests, preferences, physical and functional abilities of five of 11 sampled residents to promote each resident's mental and psychosocial well being (Residents 28, 58, 27, 10, and 9).
A review of the clinical record revealed that Resident 28 was admitted to the facility on December 8, 2017, and had diagnoses that included Multiple Sclerosis (A disease that affects central nervous system) and hypertension.
Interview with Resident 28 on September 26, 2019 at 9:05 a.m. revealed that the resident does not attend group activities held in the facility. The resident stated that she stays in her room and watches TV. A review of Resident 28's current plan of care for activities indicated that the resident prefers not to participate in group activities and that the facility activities staff will provide 1:1 room visits two times weekly.
Review of Resident 28's "Daily Recreation/Activity Participation Documentation" for the months of August 2019 and September 2019 revealed that activities staff provided 1:1 visits to the resident on August 4, 7, 8, 20, and 21, 2019; on September 10, 19, 22, 23, and 25, 2019. There was no documented evidence that activities staff had visited Resident 28 twice each week as care planned to ensure that the resident's activities needs were met and that the resident had the necessary resources/supplies to continue her individual self-directed activities since the resident did not attend group activities.
Interview with Employee 1 (Activity Aide) on September 26, 2019 at 2:05 p.m. revealed that the facility did not have enough activities staff and as a result 1:1 room visits were not being completed as care planned.
A review of the clinical record revealed that Resident 58 was admitted to the facility on August 7, 2019, and had diagnoses that included diabetes and hypertension.
During interview with Resident 58 on September 26, 2019, at 9:25 a.m. the resident stated that she does not attend group activities held in the facility. The resident stated that she stays in her room and watches TV.
A review of Resident 58's current plan of care revealed that the resident's preferences for activity participation were not identified on the resident's plan of care.
A "Recreation/Activity Evaluation" of the resident was completed on August 7, 2019 by Employee 2 (Activity Aide).
A review of the clinical record revealed that Resident 27 was admitted to the facility on September 5, 2019, and had diagnoses that included pneumonia and hypertension.
A "Recreation/Activity Evaluation" of the resident was completed on September 6, 2019, by an activity aide, Employee 2. Review of Resident 27's plan of care revealed that the resident's activities needs and/or preferences were not identified on the plan of care.
A review of the clinical record revealed that Resident 10 was admitted to the facility on August 7, 2019, and had diagnoses that included anxiety and depression.
A "Recreation/Activity Evaluation" of the resident was completed on August 8, 2019 by Employee 1, an activity aide.
Review of Resident 10's current plan of care revealed that the resident's activity and recreation needs and preferences were not included on the resident's plan of care.
A review of the clinical record revealed that Resident 9 was admitted to the facility on September 21, 2019, and had diagnoses that included diabetes and hypertension.
Employee 1, activity aide completed a "Recreation/Activity Evaluation" of the resident on September 24, 2019.
A review of Resident 9's baseline plan of care revealed no reference to the resident's activities preferences or needs.
Interview with Employee 1 on September 26, 2019 at 2:05 p.m. revealed that she and Employee 2 had completed the activities assessments of the above residents, but did not know how to initiate/implement a plan of care following the completion of the assessments. A qualified activities director, who is licensed or registered to oversee the activities program, had not signed off on any of the above assessments or initiated care planning to identify and meet activities needs.
Further interview with Employee 1 on September 26, 2019 at 2:05 p.m. revealed that since the facility's Activity Director left employment at the facility on June 27, 2019, the activity aides were conducting all activities in the facility. Employee 1 stated that the previous Activity Director developed the monthly Activity Calendars for July 2019 and August 2019 before she left, but that Employee 2, activity aide, designed the September 2019 activity calendar using activities that were planned on previous monthly calendars.
28 Pa. Code 211.11(e) Resident care plan
Previously cited 12/14/18.
28 Pa. Code 201.29 (a)(j) Resident rights
Previously cited 12/14/18.
| ||Plan of Correction - To be completed: 10/15/2019|
1. Resident #28 will be provided 1:1 room visits twice per week along with the necessary supplies and resources for self-directed activities. Resident #9, 10, 27 and 58 will have new "Recreation/Activity Evaluations" completed with preferences to be care planned accordingly.
2. New admissions and current residents have the potential to be affected by the deficient practice. A comprehensive audit of current residents will be completed utilizing the "Activities" QAPI tool department/designee by the date of compliance 10/15/2019 to ensure resident's interest, preferences, physical and functional abilities are being met with appropriate follow up is completed as needed.
3. To prevent the deficient practice from re-occuring - The activity department will be educated by the NHA/designee on the "Activity/Recreation Services Manual," before the date of compliance. All newly admitted residents will have a "Recreation/Activity Evaluations" completed with interests, preferences, physical and functional abilities care planned accordingly.
4. Utilizing the "Activity" QAPI tool – the activity director/designee will audit "Recreation/Activity Evaluations", corresponding care plan and activities documentation of 5 residents weekly x 4 weeks. Results will be reviewed with QA&A.
5. Date of Compliance is 10/15/2019.