Failure to Develop and Implement Comprehensive Care Plan for Blood Test Refusals
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident by not including interventions to address the resident's refusal of ordered weekly blood tests. The care plan also did not document the required weekly blood tests, despite physician orders for a complete blood count every Monday due to Clozapine use and a valproic acid level every Wednesday. These omissions were identified during a review of the resident's care plan and order summary report, which showed that the care plan did not reflect the necessary interventions for the resident's specific needs. The resident involved had a history of metabolic encephalopathy, schizoaffective disorder, and Alzheimer's disease, and was severely impaired in cognitive skills, requiring varying levels of staff assistance for daily activities. The resident was prescribed psychotropic medications, including Clozapine and Depakote (valproic acid), which necessitated regular blood monitoring. The Director of Nursing confirmed that the care plan should have included interventions for both the required blood draws and the resident's behavior of refusing these tests.