Failure to Update Care Plan for Resident with Complex Wound Care Needs
Penalty
Summary
Markley Rehabilitation and Healthcare Center was found noncompliant with federal and state regulations following an abbreviated survey triggered by a complaint. The deficiency centered on the facility's failure to timely update a resident's care plan to reflect evolving clinical findings, resident preferences, and refusals of care. The facility's policy requires that care plans be comprehensive, person-centered, and promptly revised as new information about a resident's condition becomes available or as their needs change. The resident involved had multiple complex diagnoses, including anemia, peripheral vascular disease, diabetes, arthritis, cellulitis, narcolepsy, Sjogren's syndrome, vasculitis, and a history of falls. Clinical documentation showed that the resident experienced new open wounds, reported adverse reactions to prescribed wound treatments, and frequently refused or altered recommended care. The resident also self-ordered and applied dressings, sometimes removing prescribed treatments and using unapproved supplies, and was inconsistent with recommended interventions such as compression therapy and wheelchair leg lifts. Despite these ongoing changes and refusals, the resident's care plan, initiated after admission, did not address the resident's practice of purchasing and applying their own treatment supplies or the associated risks and consequences. The care plan also failed to incorporate interventions related to the resident's refusals and preferences, as required by facility policy and regulatory standards.
Plan Of Correction
1. The resident's Care Plan was reviewed and revised upon readmission to the facility on 11/3/25 to ensure it accurately reflected the most current clinical findings, personal preferences, and any refusals of care. 2. Upon identification of this issue, the facility conducted a review of all residents with documented treatment refusals to verify that each resident's Care Plan accurately reflects those refusals. Any necessary updates were completed. 3. Nursing administration staff received education on the importance of updating Care Plans to reflect residents' treatment of refusals. 4. Residents with documented refusals of treatment will be audited weekly for two months to ensure their Care Plans reflect current status and include documentation of any alternative interventions or measures implemented. Audit results will be submitted to the QAPI Committee for review and recommendations as needed.