cms_AZ: 84
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 84 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 248 | E | 0 | 1 | TPN311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure that an individualized activities program was implemented for one resident (#71). Findings include: Resident #71 was admitted on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. The resident resided on the male behavioral unit. According to the annual Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR), the resident had severe cognitive impairment. Under the activity section, the documentation included that it was important to the resident to have books, newspapers and magazines available and to listen to music and to go outside for fresh air. A quarterly activities assessment dated (MONTH) 18, (YEAR), identified that the resident's favorite activities were one to one visits, coffee socials, music and conversing with family and friends. An activities care plan was developed and included as goals the following: -Resident will accept one to one visits at least twice a week. -Resident will attend group activity of interest once a week. The interventions included: -Invite to scheduled activities. -Offer to assist/escort the resident to activity functions. -Provide one to one visits twice weekly: conversation, outdoor leisure. -Socials 1-2 times weekly; cognitive games 1-2 times weekly; bingo 1-2 times monthly; education programs 1-2 times monthly; and exercise 1-2 times monthly. A review of the (MONTH) (YEAR) activity calendar revealed that 1:1 visits and coffee chats were scheduled daily, Bingo and a music program were scheduled weekly, and that fitness programs were scheduled several times a week. Review of the resident's one to one visit records from (MONTH) (YEAR) through (MONTH) (YEAR), revealed the following: July: five one to one visits were provided. August: seven one to one visits were provided. September: three one to one visits were provided. December: two one to one visits were provided January (YEAR): three one to one visits were provided. Further review of the activity records from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the following: August: The resident attended only one group activity during the month. October: The resident attended two group activities during the month. November: The resident attended only one group activity during the month. December: The resident did not attend any group activities during the month. January (YEAR): The resident did not attend any group activities during the month. During multiple resident observations, the resident was observed either in his room or sleeping in his wheelchair and was not involved in any 1:1 visits, group activities or any other type of activities. An interview was conducted on (MONTH) 2, (YEAR) at 9:10 a.m., with the Activity Director (staff #109). She stated the resident was supposed to have 1:1 visits on Wednesdays and Saturdays and that those visits should last approximately 15 to 30 minutes. Staff #109 stated the 1:1 visits would consist of sensory activities, hand massages and reading a book about horses to the resident, since he use to keep horses. Following a review of the resident's activities records, she stated that she had not followed up with the activities staff to ensure that the 1:1 visits and invitations to other activities had been provided. She also stated the activities department was short a full time activities assistant and that she needed another part time employee. On (MONTH) 1, (YEAR) at 11:00 a.m., an interview was conducted with the Director of Nursing (staff #129), who stated that the facility did not had a written policy regarding 1:1 visits. At this time, he stated that if the resident's care plan indicated 1:1 visits as an intervention, then that should be provided and that would act as the facility policy. On (MONTH) 3, (YEAR) at 8:15 a.m., another interview was conducted with staff #109. She stated that the activities assistants keep the documentation for the month's attendance and provide them to her at the end of each month, so she can file them. Staff #109 stated that although she had looked over the activity records, she had not noticed that the activities were not provided as planned. Staff #109 stated if not documented then it was not done. Staff #109 further stated the activity program is a work in progress. An interview was conducted on (MONTH) 3, (YEAR) at 8:30 a.m., with an activity assistant (staff #93). She stated that she provides activities on the unit where the resident resides. She stated that she keeps the activity attendance records for each resident until the end of the month and then turns them in to the Activities Director. At this time, she stated that she may not have recorded all the activities that the resident was involved in. Review of the Activity Assessment policy revealed the following: In order to promote the physical, mental and psychosocial well-being of residents, an activity assessment is conducted and maintained for each resident. The assessment will be conducted to help develop an activities plan that reflects the choices and interests of the resident. | 2020-09-01 |