Failure to Care Plan Resident's Refusal of Care and Medication
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a documented history of refusing care and medication. Despite multiple nurse progress notes and eMAR entries indicating repeated refusals of both medication and personal care such as showers and bed baths over several months, there was no corresponding focus, goals, or interventions in the resident's care plan addressing these refusals. The care plan did not reflect the resident's ongoing pattern of care and medication refusal, which was a significant omission given the resident's severe cognitive impairment and complex medical diagnoses, including acute on chronic heart failure, vascular dementia, and cognitive communication deficit. Interviews with facility staff, including nurses, the MDS Coordinator, the Wound Care Nurse, the Administrator, and the DON, revealed a lack of communication and follow-through regarding the resident's refusals. While some staff were aware of the refusals and discussed them in clinical meetings, others, including the MDS Coordinator and DON, were not aware or did not recall these issues being brought up. Staff consistently stated that refusals of care and medication should be included in the care plan to ensure all team members are informed and appropriate interventions can be implemented. The facility's own policy required the interdisciplinary team to develop a comprehensive, person-centered care plan with measurable objectives and time frames to address all identified needs, including those related to medical, nursing, mental, and psychosocial care. However, the lack of documentation and care planning for the resident's refusals meant that staff did not have clear guidance or interventions to address these behaviors, as required by policy and best practice.