Failure to Notify Physician of Repeated Accu Check Refusals
Penalty
Summary
Facility staff failed to implement the comprehensive person-centered care plan for a resident with diagnoses including metabolic encephalopathy, Alzheimer's disease, and dementia. The care plan, initiated on 1/3/2024, specified that staff should notify the resident's physician if the resident continued to refuse accu checks after three attempts. Despite this directive, documentation showed that the resident refused accu checks on multiple occasions in May 2025, but staff did not notify the physician as required by the care plan. Record reviews and staff interviews confirmed that the resident, who was severely cognitively impaired and required moderate assistance with activities of daily living, had a history of refusing treatment, including accu checks and insulin. The Medication Administration Record indicated refusals on several dates, and both a Licensed Vocational Nurse and the Quality Assurance Nurse acknowledged that the physician was not notified of these refusals, contrary to the care plan and facility policy.