HospitalInspections.org

Based on integrative and document review the facility failed to appropriately assess for and document patient-centered specific activity preferences for 3 of 3 patients (P3, P4, and P15) in their comprehensive care plan.

P3 was admitted in June 2024 with diagnoses of diabetes, history of stroke, memory loss, paralysis on one side or one half of their body, and obesity.

P3's therapy assessment identified P3 enjoyed visiting and listening to music.

P3's care plan failed to identify patient's preferences.


P4 was admitted in June 2024 with diagnosis of chronic obstructive pulmonary disease (COPD), major depression, non-small cell lung cancer and history of transient ischemic attack (mini-stroke), and a right leg fracture.

P4's provider notes dated 6/4/24, identified P4 liked to visit and listen to music.

P4's care plan failed to identify patient's activity preferences.


P15 was admitted in June 2024 for generalized deconditioning and mesenteric ischemia (decreased abdominal blood flow). P4's diagnoses included diabetes, history of gastric (stomach) bypass, severe protein-calorie malnutrition and heart disease).

P15's occupational therapy assessment identified patient liked to listen to music, visiting, watching TV, puzzles, listing to the radio and crafts/hobbies.

P15's care plan failed to identify patient's preferences for activities.

Interview on 7/10/24 at 2:46 p.m., with the director of nursing (DON) identified she agreed there was not a problem/goal of specific activities for P3, P4, or P15 documented on their care plan.

Interview on 7/10/24 at 3:15 p.m., with the administrator identified the process for identifying activities included an initial occupational therapy assessment that included asking the patient about their activity preferences and documenting them on their assessment. The nurses were expected to complete a comprehensive care plan problem and goals section for the patient's activity preferences as well as offer the preferred activities and document a note in the medical record. The administrator further stated she knew there was a problem with activity documentation because the nurses were not entering activity problems/goals on the care plan.

A care plan policy was requested but not received.