Failure to Incorporate Resident Preferences into Care Plan
Penalty
Summary
The facility failed to honor and incorporate a resident's expressed preferences and choices into the care planning process. A resident with alcoholic cirrhosis of the liver and ascites, who was cognitively intact, was admitted to the facility and had a physician's order for Prevalon boots to be worn while in or out of bed, with removal allowed for hygiene and skin checks. The resident's care plan included goals to prevent deterioration in activities of daily living (ADL) functional status, and nursing documentation indicated the boots were initiated for preventive care. However, clinical records, nursing progress notes, and the Treatment Administration Record (TAR) documented multiple instances where the resident refused to wear the boots and was re-educated on their purpose. Despite repeated refusals and clear documentation of the resident's choice not to wear the Prevalon boots, the resident's expressed preference was not incorporated into the comprehensive care plan. Observations confirmed the resident was not wearing the boots during multiple checks, and the resident verbally confirmed their preference not to use them. An interview with the Nursing Home Administrator confirmed that the resident's choice was not addressed in the care plan, which is inconsistent with the facility's policy to develop person-centered care plans focused on resident choices and abilities.