Minnesota s Call to Action Quality of Life Initiative for Activities F248/249 An Interdisciplinary Approach. F248 Deficiency Severity Guidance

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1 Severity Level 4 Considerations: Immediate jeopardy to resident health or safety Severity Level 3 Considerations: Actual harm that is not immediate jeopardy Severity Level 2 Considerations: No actual Harm with potential for more than minimal harm that is not immediate jeopardy Severity Level 1 Considerations: No actual harm with potential for minimal harm Question: Could a deficiency at F248 ever be cited at Immediate Jeopardy? (Level 4) Answer: No. Immediate jeopardy is not likely to be issued. It is unlikely that noncompliance could place a resident or residents into a situation with potential to sustain serious harm, injury, or death. CMS cannot conceive of any situation in which a F248 deficient practice could lead a resident to such a severe outcome. Question: What about Severity Level 1? Answer: Severity Level 1 is not an option because any facility practice that results in a reduction of psychosocial well-being diminishes the resident s quality of life. The deficiency is, therefore, at least a Severity Level 2 because it has the potential for more than minimal harm. Activities is a key resident right, and is part of the Quality of Life section of the regulations. F248 is an outcome-oriented requirement in that compliance is determined separately for each resident sampled. The survey team s review of the facility s activities program is conducted through a review of the individualization of activities to meet each resident s needs. Below are excerpts of F248 deficiencies. Residents stated at the resident group meeting that there was nothing to do for men. There was nothing to do after supper and it was too early to go to bed. Resident #1 stated, there just wasn't anything for the men to do, after supper it s dead, and it s too early to go to bed." Resident #2 agreed stating, " There isn't anything for men. They had that Pie thing, but the women come to that too. I would like to get together with other men and just BS. I would also like to play cards." He named a few other residents that he thought might be able to play cards with him. He added that the evenings got long and there just wasn't much to do. Page 1

2 Resident #1 stated he would like to build models. He stated, " I just sit and watch TV because there's nothing else to do. It's the same for my roommate," and pointed over to his roommate who was sleeping on his bed. The Activity Director indicated that they really didn't have anything just for men. They had started Pie Day for the guys, but then they had allowed the women to come too so there really wasn't anything just for them. She noticed that resident #2 was just sitting in his room doing nothing, so she had set up a floor mat that he could string with rubber rods on a small table in his room. She stated that a while ago the residents had said something about wanting more activities in the evening, so they had added Bingo at 6:15 on Tuesday and a Movie at 6:00 pm on Friday. After looking at the date these two activities started, she added that she didn't realize that it had been over a year ago, and would bring this up with the residents again Severity Level: Level 2. Rationale: Severity Level 2 indicates noncompliance that results in a resident outcome of no more than minimal discomfort and/or has the potential to compromise the resident s ability to reach his or her highest practicable level of well-being. The potential exists for greater harm to occur if interventions are no provided. In assessing each resident, the staff should be noting what the resident prefers, lifelong interests and are adaptations needed. Each resident is entitled to an individualized activity program that meets his or her interests. Non-compliance includes complaints of boredom and/or reports that there is nothing to do, accompanied by expressions of periodic distress, that do not result in maladaptive behaviors (e.g., verbal or physical aggression). Resident #1 stated she liked the activity pokeno, and it was the only activity that she attended, and that the activity would be held the following day at 10:00 am. The resident called it "adult bingo" and also indicated she used to enjoy playing cards, but there were no card games offered and she would like more adult activities. The following day at 9:30 am, an announcement was made on the intercom that pokeno would be held from 10:00 am to 10:30 am. The resident was still in bed and had not received morning cares. The resident was asked by the surveyor if the staff were aware of her desire to attend the pokeno activity, the resident replied "they don't care. It s the only activity that I do attend and I can't get there now unless they just wash my face." At 9:45 am, a nursing assistant Page 2

3 entered the resident s room to provide morning cares. The nursing assistant asked the resident about the activity, and the resident replied, "yes, it starts at 10:00, I think it s getting late". At 10:20 am, the resident was again asked about attending pokeno, and the resident replied "I'm not going any further than this, by the time I get down there it will be over". When interviewed, the nursing assistant stated she was unaware of the resident s wish to attend the pokeno activity until the "activity guy" came around a few minutes before 10:00 am. The resident was admitted to the facility four months before. The recreation history and assessment completed by the activity director identified that the resident liked the card game whist and the game pokeno and was willing to attend activities. The current resident care plan did not identify activities or interests that had been identified on the admission assessment. The activity director verified the resident had not received morning cares in time to attend the pokeno activity the previous day. The activity director was not aware if nursing was informed of the resident s interests or desire to attend this activity. The activity director also stated he didn't know the resident had an interest in playing cards. On interview with the registered nurse, it was verified that the nursing staff were unaware of the resident s wish to attend the activity. Severity Level: Level 2 Rationale: Severity Level 2 indicates noncompliance that results in a resident outcome of no more than minimal discomfort and/or has the potential to compromise the resident s ability to reach his or her highest practicable level of well-being. The potential exists for greater harm to occur if interventions are no provided. The information from the assessment needs to be specific enough for the facility to develop a care plan to meet the resident s interests and to be able to understand what specific adaptation and assistance are needed. The facility is responsible for activities, not just the activities department. The interdisciplinary team should take into account various components of the resident s schedule in order to optimize resident choice to the extent possible. Observations were made of cognitively impaired residents who resided on a secure unit after the evening meal. In the main dining room 17 residents were gathered. Resident #1 was intermittently singing, "Sweet Adeline" in a loud voice. Another resident said, "Who's screaming? Be quiet or go home." There were 2 staff members in the dining Page 3

4 room, and no diversion or activities were offered to the residents. Four residents who sat at a table near resident #1 told him, "shut up". Five minutes later, one resident was yelling, one resident was singing, one resident was chanting, "get home, get home", while another resident said, "help, help, help". A resident turned to the surveyor and said, "its terrible", and when questioned what was terrible, she replied, "The singing. Don't you go crazy in here?" At 6:10 pm a staff member gave resident #1 a magazine and a sucker. There were 15 residents in the dining room, sitting at the tables, and not participating in any activity. At 6:20 pm staff put on some music and gave 3 residents music books for a sing-a-long. One of the residents pushed the book away and said, "I want to play cards". One resident sang from the book. The television was on in the background, however no one was watching it. At 6:25 pm a resident questioned the surveyor, can you play cards with me?" At 6:30 pm 14 residents were gathered in the large dining room, sitting at tables, not participating in any activities. Resident #1 began yelling, "Ahhh Ahhh", and singing "Daisy, Daisy". Staff asked the resident to sing a little quieter. At 6:40 pm 13 residents were in the large dining room, sitting at tables, not participating in any activities. Resident #1 was singing, "Easter Parade", another resident repetitively yelling, "where are my friends?" One resident yelled, "shut up," while another said, "I sure hate to listen to this all night". At 6:45 pm one staff member was present in the dining room. A resident walked by resident #1 and said, "You're a screwball". At 6:50 pm there were no staff in the dining room, and one resident yelled, "I want to go to bed" twenty-four times. At 6:55 pm resident #1 was screaming and a resident turned to the surveyor and said, "this is a crazy house". Another resident started to approach resident #1, and the resident next to the surveyor yelled, "Hit him!" The resident went to resident #1 and took his hat. Staff intervened, and requested resident #1 talk in a soft voice. At approximately 7 PM resident #1 was taken to his room. At 7:10 pm there were 12 residents gathered in the dining room, sitting at tables. At 7:15 pm one of the residents said, "It's so quiet in here now, maybe we should start yelling". The residents were not engaged in any activities. Two residents asked the surveyor if I, the surveyor, was writing down how noisy it was around here. Three other women were grimacing and getting upset with the noise. One resident plugged her ears. Another resident was standing at the desk frowning. At 7:40 pm a resident went to the nurse and questioned if there was any bingo. The nurse said, "there s not much going on". At 8 pm there were 13 residents sitting at various tables in the dining, not participating in any activity. Page 4

5 Upon interview with the nurse she said evening staffing included 1 nurse, and 4 nursing assistants. One nursing assistant worked 11 am until 7 pm and was responsible for the evening activity program. However, the nursing assistant was also responsible for covering staff when they took their breaks and for giving resident baths. Severity Level: Level: 3 Rationale: Severity Level 3 indicates noncompliance that results in actual harm and can include but may not be limited to clinical compromise, decline, or the resident s inability to maintain and/or reach his/her practicable well-being. Some residents who have dementia may have a pattern of aggression or anxious behavior at a similar time daily. The facility should try to individualize their approaches to residents with distressed behavior. Activities should be presented prior to when symptoms usually present themselves. A negative outcome of anger caused aggression that could lead to injuring self or others. Verbal aggression can be manifested by threatening and screaming. Physical aggression can be manifested by resident responses of hitting. Page 5

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