Failure to Develop Comprehensive Care Plan for Noncompliant Resident
Penalty
Summary
Facility staff failed to develop a comprehensive care plan addressing all of a resident's needs, specifically for a resident with paraplegia, osteomyelitis, urinary tract infection, indwelling catheter, and MRSA. The resident was cognitively intact and had a significant change in status as indicated by the most recent MDS. Clinical record review and staff interviews revealed that the resident frequently refused medications, treatments, hygiene, and incontinence care, and would often leave the facility for extended periods, missing scheduled treatments and medications. Despite documentation of the resident's noncompliance and refusals in various records and staff interviews, the care plan only addressed behaviors related to rejecting wound treatments and medications, without including specific interventions for missed treatments or medications, or for hygiene and incontinence care. Multiple staff, including the LPN, CNA, physician, wound care nurse practitioner, and MDS coordinator, confirmed the lack of detailed interventions in the care plan. The issue was acknowledged by the MDS coordinator and presented to the DON, with no additional information provided before the exit conference.