Failure to Individualize Care Plan for Resident Refusals and Preferences
Penalty
Summary
The facility failed to develop and implement an individualized comprehensive care plan (ICCP) for a resident who was non-compliant with receiving ordered treatments and meals prepared by the facility. The resident had significant medical conditions, including a stage 4 pressure ulcer, malignant neoplasm of the rectum, and a right fibula fracture, and was assessed as having moderately impaired cognition. Despite documented refusals of wound care treatments and prescribed medications on multiple occasions, as well as repeated refusals of facility-prepared meals in favor of home-cooked food, the care plan did not address these refusals or the resident's preferences. Documentation in the medical record, treatment administration record, and nursing progress notes confirmed the resident's pattern of refusing both treatments and meals. The resident's spouse also communicated the resident's preference for home-cooked meals to nursing staff. However, the comprehensive care plan lacked any focus or interventions related to the resident's refusals or meal preferences, contrary to the facility's own policy requiring incorporation of personal and cultural preferences and documentation of services not provided due to resident choice.