Failure to Develop Person-Centered Care Plans for Skin Integrity and Personal Care Refusals
Penalty
Summary
The facility failed to develop person-centered care plans for two residents regarding a new pressure area and refusal of facial hair removal. For one resident with multiple diagnoses including chronic kidney disease, hemiplegia, and venous insufficiency, staff observed an open area on the left inner buttock cheek. Although the resident had existing care plans addressing skin integrity and mobility, there was no documentation of a skin incident, no treatment order, and no care plan specifically addressing the new open area. Staff interviews confirmed that the required procedures for new skin issues, such as incident reporting, physician notification, and care plan initiation, were not followed. For another resident with diagnoses including malnutrition, anxiety, and depression, staff and the resident confirmed repeated refusals of assistance with facial hair removal. The care plan noted a potential self-care deficit and refusal of showers but did not document the resident's specific refusals regarding facial hair care. Staff interviews indicated that refusals were documented in the electronic medical record but not reflected in the care plan, contrary to facility policy. The unit manager confirmed that such refusals should have been included in the care plan documentation.