Failure to Notify PCP of Resident's Refusals of Care and Treatment
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not notifying the resident's Primary Care Provider (PCP) of repeated refusals of showers/baths and wound care treatment. The resident, who had diagnoses including heart failure, diabetes mellitus, and cellulitis, was assessed as having no cognitive impairment and was able to make decisions. Physician orders were in place for daily moisturizing ointment to the feet and specific wound care for cellulitis on the right lower leg. Documentation showed that the resident refused wound care on multiple occasions and refused showers/baths on several dates. Despite these refusals, there was no evidence in the progress notes that the PCP was notified of the missed wound care treatments or showers/baths. Interviews with facility staff, including a CNA, LVN, DSD, and DON, confirmed that the facility's policy required notification of the PCP and documentation of refusals, but this was not done. The facility's policies on care and wound management also specified that the physician and interdisciplinary team should be informed of such refusals, which did not occur in this case.