Failure to Update Care Plan After Resident Refusal of Blood Draw
Penalty
Summary
A deficiency occurred when the facility failed to develop and update a comprehensive, person-centered care plan for a resident who refused a blood draw for a complete blood count (CBC) test. The resident, admitted with diagnoses including metabolic encephalopathy, altered mental status, type 2 diabetes mellitus, and essential hypertension, was noted to be moderately impaired in thought process and required substantial assistance with activities of daily living. The resident experienced episodes of blood in the stool, prompting orders for STAT laboratory tests, including a CBC and occult blood test. Despite the physician and nurse practitioner being notified and orders being placed, the resident refused the CBC blood draw. Multiple staff members, including RNs and laboratory staff, attempted to encourage the resident to comply, but the refusal persisted. Documentation of the refusal, the attempts to obtain the sample, and communication with the medical team were either incomplete or missing. Staff interviews revealed that required steps per facility policy—such as offering the procedure three times, explaining risks and benefits, notifying the physician, and documenting all actions—were not fully carried out or recorded in the resident's medical record. Further review confirmed that no care plan was developed to address the resident's refusal of the CBC blood draw. Both nursing staff and the Director of Nursing acknowledged that a care plan should have been created to identify interventions for the refusal and to monitor the resident's condition. The facility's policy required a baseline care plan for each resident, but this was not implemented in this case.