Failure to Develop Care Plan for Resident's Refusal of Showers
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing a resident's repeated refusals to shower or bathe. Despite the facility's policy requiring the interdisciplinary team to create a person-centered care plan that includes measurable objectives and timeframes for all identified needs, there was no care plan in place for the resident's ongoing refusals. The resident, who was cognitively intact and able to make decisions, had a documented history of refusing showers on multiple occasions, as evidenced by shower sheets and staff interviews. However, these refusals were not documented in the resident's progress notes, and no care plan was initiated to address the refusals or to outline alternative interventions or education efforts. Interviews with nursing staff and review of facility records confirmed that required documentation and follow-up actions were not completed. The assigned CNAs and licensed nurses did not consistently report or document the refusals as required by facility policy, and missing shower sheets were not followed up by medical record staff or the Director of Staff Development. The lack of a care plan for the resident's refusals meant that individualized, consistent care was not ensured, and the facility's own procedures for addressing such refusals were not followed.