Plan of Correction. Writing a Plan of Correction

Transcription

1 Plan of Correction Writing a Plan of Correction

2 The Deficiency 1) Resident #2 had pertinent diagnoses of dementia with agitation, anxiety and restlessness. The Minimum Data Set (MDS) assessment dated February 19, 2009 documented the resident had memory deficits and moderate cognitive impairment and also documented the resident had difficulty making himself understood and understanding others. An annual activity note dated February 4, 2009, contained in the interdisciplinary progress notes, documented the resident often fell asleep many times during the day and needed to be awoken to participate. The activities note documented the resident no longer had an interest in playing Bingo and would be invited and assisted to music programs, intergenerational programs and special events. The comprehensive care plan (CCP) last updated on February 10, 2009 documented the resident had a need for socialization and would be invited and assisted with transportation to activities of interest which included hymn singing, worship, music, children's activities, special events and creative dining experiences.

3 The Deficiency On April 2, 2009 at 10:45 AM, the resident was seated in his wheelchair in the main dining room waiting for the scheduled activity to began which was a visit from children from the neighborhood preschool. The resident was sleeping. A few minutes later at 10:50 AM, the activities' director came into the main dining room. A facility volunteer who was assisting during the activity, pushed the resident in his wheelchair up to a nearby table as he continued to sleep. The activity started which included songs sung by the children, a balloon toss between the children and the residents, a holiday craft project, a story read by one of the residents to the children and a beverage served to both the children and the residents. Later that same day at 11:00 AM, the children and residents were tossing balloons back and forth to each other. Resident #2 continued to sleep in his wheelchair at a table. The surveyor continued to observe the resident seated in his wheelchair at the table asleep while the holiday craft project was in progress and for the duration of the interaction with the children which ended at 11:30 AM. At this time, the activities director began passing beverages to the residents and a beverage was put on the table in front of Resident #2, who was still asleep. A few minutes later at 11:35 AM, the resident coughed twice and woke himself up. There was no attempt by staff or volunteers to engage the resident during the activity.

4 The Deficiency When interviewed on April 3, 2009 at 11:15 AM, the activities director revealed for those residents who were alert and oriented, they were capable of becoming engaged during activities on their own. For those residents who had lower cognitive abilities, staff would need to interact with them, helping them to become attuned to what was going on in the environment. The activities director further stated she assumed volunteers who assisted during the activity would engage residents. The activities director said Resident #2 was given the opportunity to participate by "just being there." She said she chose to focus on those residents who could benefit from certain types of programs. The activities director commented Resident #2 participated in Bingo earlier in the week and she was pleased he had a good experience during this activity. In summary, the facility did not ensure an attempt was made to engage this resident during the activity, giving him the opportunity to participate in a program which had been identified as one of particular interest to him.

5 The Deficiency 2) Resident #10 had pertinent diagnoses of Alzheimer's dementia and general debility (weakness or lack of strength). The CCP dated July 23, 2008, documented the resident would be provided with a weekly activities calendar, and would be invited and provided with transportation to music programs. The CCP dated October 7, 2008, documented the resident would engage in self-directed activities with direct assistance when needed and would attend group programs when able. On January 7, 2009, the CCP documented the resident was socially appropriate and able to converse when spoken to. 3)Resident #11 had diagnoses including Parkinson's disease and dementia. The CCP dated December 3, 2008, documented the resident would be provided with an activities calendar on a weekly basis, would be invited/provided transportation to activities (music, special events), provided sensory stimulation, invited to the main dining room for social/dining activities. The resident enjoyed balloon toss, music, and visually stimulating activities. This would be managed by the activities' staff and, on February 25, 2009, the care plan was updated and documented the resident was adapting to the group setting in the main dining room.

6 The Deficiency On April 2, 2009 at 11 AM, both Residents #10 and 11 were seated in their wheelchairs with their lap buddies in place in the main dining room, participating in a balloon toss activity with visiting preschool children and the activities director. Several minutes later at 11:15 AM, when the children were finished with the balloon toss activity, residents who were not already seated at tables in the dining room, were assisted to tables by staff/volunteers to participate in a holiday craft project with the children. Neither of these residents were assisted to a table and remained positioned in their wheelchairs with their lap buddies in place, away from tables where other residents were either participating in or observing the holiday craft project in progress.

7 The Deficiency When interviewed on April 3, 2009 at 11:15 AM, the director of activities revealed she could not have every single person involved in every single activity. She stated, "I take on a lot". She felt these residents would not be able to participate in the craft project, although their not being brought to a table was not done purposely. The activities' director said it was beyond her ability to have everyone involved. She stated, " I'm glad it was only two (residents who were not included at the table)."

8 The Deficiency In summary, the facility did not ensure these Residents #10 and 11 were provided with the same opportunity to fully participate in all aspects of the activity that was being offered to other residents attending the activity

9 Within 10 Days of Receiving the Deficiency You will need to re-assess the residents mentioned in the deficiency to ascertain if they are interested in the activities that you have planned for. For Resident #2 you should talk with the Care Plan Team and Nursing and perhaps the Physician to see why the residents sleeps all day. There might be a medical or physical reason for this behavior. If there is a reason, then you will need to adapt his interests and leisure needs to meet his medical situation For Resident(s) #10 and #11 you will re-assess their interests and make sure that they are engaged in all activities that they choose to attend

10 Within 30 Days of the Deficiency You will need to re-assess using your Initial Assessment Form all of the residents in your facility. This is to assure that the activities department is meeting their needs and interests. You will also need to educate staff and volunteers on how to engage residents in activities programs. Several in-services as well as continuing education is needed to help staff and volunteers learn new skills to make the activities meaningful and enjoyable for all residents. You will also have to address the individual needs and interests of your residents in their care plans within 30 days that would be the residents that were cited in the deficiency

11 Within 90 Days of the Deficiency You will need to update all of the care plans for all of the residents to reflect their individual needs and interests. It is apparent throughout the deficiency that the residents are adapted to the activity and do not have the activity adapted for their needs and interests. There should be a review of the Initial Assessments, MDS3.0 and interviews with the residents to change the activities calendar and to design programs that are adaptable to the needs and interests of the residents

12 Ongoing for at least 1 year You will be formulating a Quality Assurance study to assure that all of the needs and interests of the residents will be met Volunteers assisting with activities programs will be attending inservices that will assist them in learning about how to engage residents in activities Staff (including the Activity Director) will be encouraged to attend workshops and continuing education concerning involving and individualizing activities to meet the needs and interests of the residents In-services for all staff including Nursing Staff will be offered to encourage staff participation in engaging residents in meaningful activities to the individual residents

13 Task Date to be Completed Staff Involved Audit Tool Reassess Residents affected by deficiency Within 10 days of receiving deficiency statement Assessment Audit Tool Review medical issues of resident #2 Within 10 days of receiving deficiency statement Nursing Physician Care Plan Review Care Plans and update of Resident s #10 and #11 Within 10 days of receiving deficiency statement Nursing Care Plan In-service Staff and volunteers 30 Days from receiving the deficiency statement In-Service Coordinator Consultant Certificates of Completion Attendance Records

14 Task Date to be Completed Staff involved Audit Tool Reassess all residents Within 30 Days of receiving deficiency statement Activity Assessment Audit Tool Update Calendar to reflect the needs and interests of the residents Within 90 days of receiving deficiency statement Resident Committee QA Audit Tool Update all resident care plans to reflect the individualized needs and interests of the residents Within 90 days of receiving deficiency statement IDCP Team QA audit tool

15 Task Date to be Completed Staff involved Audit Tool QA Study Study the individualized needs and interests of the residents Ongoing/Quarterly Basis Volunteers Residents Assessment Audit tool Care Plans MDS 3.0 In-service staff and volunteers on adapting activities to meet the needs and interests of the residents Ongoing/ Quarterly Basis In-Service Coordinator Volunteers Consultant Certificates of Completion Attendance Records Staff (including Director) will attend workshops and meetings of other activity professionals specifically to learn about individualizing activities offered Ongoing Administrator Certificates of Attendance

16 Now What?????? You will need to develop the Audit Tools and the QA Study to assure that the activities programs is meeting the individual needs and interests of the residents. You will need to re-read the Interpretive Guidelines of 2006 to learn about the interpretation of the activities regulations You will also have to make sure that all new staff, new volunteers and all staff know how to engage residents during activities