Failure to Update Care Plan for Resident's Bathing Refusals
Penalty
Summary
The facility failed to update and revise a resident's care plan to reflect specific care needs, particularly regarding the resident's refusal of showers or baths. The resident, who was admitted with diagnoses including muscle wasting, cognitive communication deficit, and bed confinement status, had a BIMS score of 0, indicating a lack of cognitive intactness. Despite the resident's frequent refusals of showers or baths, as documented in the clinical records, there was no follow-up documentation or reasoning provided for these refusals. Additionally, the care plan did not include interventions for the resident's refusals. Interviews with facility staff revealed that the resident did not refuse showers or baths when approached by certain staff members, suggesting a need for specific approaches to encourage compliance. However, this information was not communicated effectively among the staff, and the care plan remained unchanged. The facility's administration confirmed that no care plan or interventions were developed or implemented to address the resident's refusals, leading to a deficiency in meeting the resident's care needs.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report. F0657-CARE PLAN TIMING AND REVISION 1. Resident R1's plan of care was updated on 12/11/2024. 2. An audit was conducted of all current residents care plans as it relates to refusals of care. Any variances were addressed and noted on the facility audit tool. 3. Nursing staff were educated by the Director of Nursing/Designee on communication regarding resident refusals of showers/bathing and ensuring the residents plan of care is up to date. 4. The Director of Nursing/Designee will conduct an audit of the care plans of 10 residents weekly for 4 weeks, and 10 residents monthly for 2 months to ensure refusals of care for showers/bathing are appropriately care planned. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.