Failure to Develop Comprehensive Care Plan Addressing Resident Noncompliance
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including end stage renal disease, diabetes, heart failure, peripheral vascular disease, and arterial wounds. Although the resident's care plan addressed some medical needs such as renal failure, dialysis, and nutritional risks, it did not include interventions or measurable objectives related to the resident's specific behaviors that impacted her care. These behaviors included not offloading pressure from her feet, not wearing heel protectors, bearing weight against recommendations, refusing dialysis, consuming excess fluids and soda, and not following dietary restrictions. Staff interviews revealed that the resident frequently removed her heel protectors, sat up in her chair, requested ice despite fluid restrictions, and sometimes refused dialysis appointments. Staff and family education was provided regarding the importance of adhering to medical recommendations, but the care plan was not updated to reflect these ongoing behaviors or the interventions used to address them. The resident's family also brought in outside food that was not consistent with her prescribed renal diet, and staff documented these occurrences but did not incorporate them into the care plan. The facility's own policy required that the care plan identify any care or service declined by the resident, the associated risks, and the efforts made by the interdisciplinary team to educate the resident and her representative. However, the care plan did not document the resident's noncompliance or the facility's interventions to address these behaviors, resulting in a lack of guidance for staff and potential gaps in care coordination.