Failure to Address Repeated Refusals of Care in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical diagnoses, including Multiple Sclerosis, Cognitive Communication Deficit, and a history of Transient Ischemic Attack. Despite the resident's moderate cognitive impairment and repeated refusals of essential care and services such as wound care, perineal care, medication administration, showers, and nutritional supplements, the care plan did not include any interventions to address these refusals. Documentation in the resident's progress notes showed numerous instances where the resident declined wound debridement, application of prescribed creams, blood sugar checks, and other necessary treatments over an extended period. Interviews with the DON and Administrator confirmed that the resident's refusals should have been addressed in the care plan, with specific interventions to encourage acceptance of care. The facility's own policy required that the care plan identify declined care, the associated risks, and efforts by the interdisciplinary team to educate the resident and seek alternative solutions. However, the care plan lacked these elements, resulting in a failure to meet the resident's identified needs as outlined in the comprehensive assessment.