Failure to Develop Care Plan for Resident Refusals of Care
Penalty
Summary
A deficiency was identified when the facility failed to develop a care plan addressing a resident's repeated refusals of care, specifically related to turning, repositioning, and wound management. The resident was admitted to the facility and subsequently documented by multiple staff, including a wound nurse practitioner, nurse practitioner, wound nurse, CNA, and RN, as being non-compliant and resistant to care, often refusing to be turned, repositioned, or to have wounds treated. Despite these ongoing refusals and behavioral challenges, a review of the resident's care plan revealed no evidence of individualized objectives, goals, or timeframes to address the refusals of care. Staff interviews confirmed that a care plan for refusals should have been completed but was not present.