Failure to Develop and Implement Care Plan for Resident Refusals
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan for a resident who frequently refused multiple aspects of care. The resident, who was admitted with a surgical wound and had the capacity to make decisions, repeatedly refused activities of daily living (ADL) care, dialysis, medications, repositioning, and skin and wound assessments. These refusals were documented in the medical record and confirmed by both the Wound Care Nurse and the Director of Nursing (DON). Despite the resident's ongoing refusals, the care plan did not address these behaviors or outline strategies to manage or respond to the refusals. The lack of a care plan problem related to the resident's refusals resulted in the surgical wound with sutures not being assessed, monitored, or cared for until several months after admission. The wound and sutures were only discovered and addressed after a significant delay, during which the resident also developed other unrelated wounds. Interviews with facility staff, including the Wound Care Nurse and the DON, confirmed that the resident's refusals were not incorporated into the care plan. The DON acknowledged that the absence of a care plan addressing the refusals contributed to the missed assessment and care of the surgical wound. The deficiency was verified through medical record review, staff interviews, and direct observation of the resident refusing care.
Plan Of Correction
F0656 - Develop and Implement Comprehensive Person-Centered Care Plan Immediate Corrective Action: On September 2, 2025, a treatment care plan was developed for Resident #10 for multiple refusals. Residents Affected: On September 2, 2025, the RN Supervisor reviewed all residents with refusals to ensure that care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 3, 2025, on the process for developing, reviewing, and updating care plans for refusals care plan. Monitoring of Corrective Action: The DON or their designee will review care plans for all new and all wounds in the weekly wound meeting to verify compliance. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025