Failure to Update Care Plan for Resident's Refusal of Pressure Ulcer Treatment
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plan to include a resident's repeated refusals of pressure ulcer treatments and management. The care plan did not document the resident's refusals to have dressing changes performed, wound vac dressings assessed, or wet to dry dressings applied, despite multiple instances of such refusals being recorded in the nursing notes. The facility's policy required that the care plan describe services not provided due to the resident exercising their right to refuse treatment, but this was not reflected in the resident's care plan. The resident involved was cognitively intact, with a history of type two diabetes mellitus and an unstageable pressure ulcer of the sacral region. Nursing notes documented several occasions where the resident refused wound care, dressing changes, and interventions related to the wound vac, as well as non-compliance with turning and repositioning protocols. Despite these documented refusals and non-compliance, the care plan was not updated to reflect the resident's choices or the facility's response to these refusals.