Failure to Update Care Plan for Resident's Evolving Clinical Needs and Refusals
Penalty
Summary
The facility failed to timely update a resident's care plan to reflect evolving clinical findings, resident preferences, and refusals of care. Specifically, the care plan did not address the resident's actions of purchasing and applying their own wound treatment supplies, nor did it include interventions related to the risks and consequences of these self-administered treatments. The care plan also did not incorporate the resident's refusals of prescribed wound care treatments, such as Dakin's cleansing, gauze, wound gel, and calcium alginate, which the resident declined due to reported burning sensations. Additionally, the care plan did not reflect the resident's inconsistent use of compression therapy, refusal of heel lift boots, and non-compliance with PCP recommendations for wheelchair leg lifts. The resident in question had multiple complex medical diagnoses, including anemia, peripheral vascular disease, diabetes, arthritis, cellulitis, narcolepsy, Sjogren's syndrome, vasculitis, and a history of falls. Despite these conditions and ongoing changes in wound status, the care plan was not revised to address the resident's self-management behaviors or to document the involvement of the interdisciplinary team in response to these changes. Observations and staff interviews confirmed challenges in assessing treatment effectiveness due to the resident's removal of prescribed dressings and application of unapproved dressings, as well as discrepancies between staff and resident reports regarding treatment refusals.