Failure to Implement Care Plan and Notify Conservator of Care Refusals
Penalty
Summary
The facility failed to fully implement a care plan for a resident with mild cognitive impairment, COPD, and congestive heart failure, who required set up and reminders for daily hygiene care. The care plan specified that the resident's conservator should be notified whenever the resident refused any portion of daily care. However, documentation from July through October showed that while the resident was mostly compliant, there were occasions when care was not provided and no documentation was completed. Medication Administration Records indicated that notification to the conservator for refusals of care was only documented on shower days, and nurse's notes did not reflect any notifications for refusals of care during a specified period. Interviews with the resident and staff revealed that the resident often chose not to perform daily hygiene tasks, such as washing, tooth brushing, or changing clothes, except on shower days. The primary nurse aide confirmed that the resident refused assistance with certain tasks and claimed to complete them independently. The DON acknowledged that the facility had agreed to notify the conservator of all refusals but was unaware that this was not consistently documented as required by the care plan. The facility's care plan policy required that care plans be developed and implemented with the resident and/or caregiver, but this was not fully adhered to in this case.