Care Plan Not Updated to Reflect Resident's Refusal of Weight Monitoring
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for a resident with multiple complex medical conditions, including cerebral infarction, cerebral palsy, schizophrenia, epilepsy, and dysphagia. The resident had severely impaired cognition, was incontinent, and completely dependent on staff for all activities of daily living. Despite documented refusals by the resident to be weighed, this behavior was not reflected in the comprehensive care plan, even though the care plan included interventions related to weight monitoring due to a history of unplanned weight loss. Staff interviews and record reviews revealed that the process for documenting refusals involved CNAs noting the refusal in the EHR, which should have triggered further documentation by nursing staff and the MDS nurse in the care plan. However, this process was not followed, resulting in the resident's refusal to be weighed not being incorporated into the care plan. The facility's policy required that the care plan reflect the resident's expressed wishes regarding care, but this was not done, and the omission was acknowledged by the DON and MDS nurse during interviews.