Failure to Develop and Implement Person-Centered Care Plans for Refusal of Care
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents regarding their refusal of care, specifically related to nail care and the required notifications to responsible parties and physicians. For one resident, who was cognitively intact and had multiple diagnoses including schizophrenia, pain, and depression, observations revealed long, jagged fingernails and toenails. Although the care plan indicated interventions such as notifying the physician and responsible party upon refusal of care, there was no documentation that these notifications occurred. Interviews with nursing staff and the interim director of nursing confirmed that refusals and notifications were not properly documented or followed up as required by the care plan and facility policy. Another resident, who was non-verbal and severely cognitively impaired with a history of traumatic brain injury and other significant medical conditions, was observed with long, thick, and untrimmed toenails. Staff interviews indicated that nail care should have been addressed and that a care plan for refusal of care should have been initiated when the resident first refused. However, the care plan for non-compliance was only started after the deficiency was identified, and there was no evidence that staff had previously communicated or documented the resident's refusals or the necessary notifications to the responsible party or physician. Facility policy requires that comprehensive, person-centered care plans with measurable objectives and timetables be developed and implemented for each resident, including documentation of refusals and notifications. The lack of timely care plan development, implementation, and documentation for both residents resulted in a failure to meet these requirements, as confirmed by staff interviews and record reviews.