Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident, identified as Resident R70, who was admitted with diagnoses including rhabdomyolysis, hypertension, and malignant neoplasm of the prostate. Despite the facility's policy requiring a comprehensive care plan with measurable objectives and time frames, Resident R70's care plan did not address the resident's repeated refusals of various treatments, such as activities of daily living, medication, physical therapy, and occupational therapy, which occurred several times weekly from October 1, 2024, to January 8, 2024. A review of the clinical records and an interview with a licensed nurse confirmed the absence of a care plan addressing these refusals. This deficiency was identified during a survey, as the facility did not meet the requirements outlined in 28 Pa. Code: 211.12 (d) (1) (5) Nursing services and 28 Pa. Code 211.10 (c) Resident care policies.
Plan Of Correction
The Care Plan for Resident R70 was immediately updated on 01/09/2025 to reflect Resident R70's refusals of medications, PT, OT, and Activities of Daily Living. Following the completion of the survey, the care plans for all the current residents were reviewed. Any resident that was refusing medications, treatments, therapies, ADLs, etc., had their care plans updated to reflect these refusals. Upon admission to the facility, refusals of care will be monitored by the Interdisciplinary Team (which would include our nursing, therapy, social service, activities, and dietary team members). The care plans for these residents will reflect any refusals of medications, treatments, therapies, ADLs, etc. The RNAC will be responsible for monitoring the completion of these care plans and review them prior to each resident assessment and care conference.