Failure to Develop Care Plan for Resident Refusing Care
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan for a resident known to refuse care and exhibit non-compliant behaviors. The resident, who had diagnoses including Hepatic Encephalopathy, Essential Hypertension, and Osteoarthritis, was cognitively intact and required significant assistance with daily activities. Nursing progress notes documented three separate occasions where the resident refused care, yet a care plan addressing these refusal behaviors and non-compliance was not initiated or documented. Interviews with facility staff, including an LPN, the DON, and an RN, confirmed that the resident's refusal and non-compliance behaviors were known but not reflected in the care plan. Staff acknowledged that such behaviors should have been captured in a behavior or refusal of care care plan, but this was not done. The facility's policy requires that care plans include measurable objectives and timeframes to address identified needs, but this was not followed for the resident in question.