Failure to Implement and Update Comprehensive Care Plans for Resident Refusals and Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents as required by policy. One resident, who was cognitively intact and had a history of refusing care, had multiple documented instances of care refusal. Despite these occurrences, there was no care plan initiated to address or reflect the resident's refusal behaviors. Interviews with nursing staff and the Director of Nursing confirmed that a behavior or refusal of care plan should have been implemented but was not, and that the resident's non-compliance was known but not documented in the care plan. Another resident, who had multiple diagnoses including diabetes, end stage renal disease, and chronic obstructive pulmonary disease, was at risk for pressure ulcers and had a history of a Stage 4 sacral pressure ulcer. After the ulcer was resolved and the resident was subsequently readmitted to the facility with the ulcer reopened, there was no documented evidence that the pressure ulcer care plan was reactivated upon readmission. The facility's policy required care plans to be updated with new or recurring conditions, but this was not done for the resident's reopened pressure ulcer.