Failure to Incorporate Resident Choices into Care Plan
Penalty
Summary
The facility failed to honor and incorporate a resident's expressed preferences and choices into the care planning process. Clinical record review showed that the resident, who was cognitively intact and had a history of lobar pneumonia, repeatedly chose not to participate in various aspects of care, including use of a BiPap machine, occupational therapy, nebulizer treatments, blood pressure readings, meals, weights, skin treatments, and bathing. Despite these documented choices, the resident's care plan did not address or reflect these specific preferences or provide tailored interventions to meet the resident's needs related to their decisions to refrain from certain care activities. Facility policy required the development of a comprehensive, person-centered care plan focused on resident choices and abilities, with the goal of maintaining or improving functional abilities and quality of life. However, the care plan in effect at the time of the survey did not accurately represent the resident's expressed choices. This was confirmed in interviews with the Nursing Home Administrator and Director of Nursing, who acknowledged that the resident's preferences were not incorporated into the care plan.