Failure to Revise Care Plan for Ongoing Medication Refusal
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, resident-centered care plan with specific, measurable objectives and interventions for a resident who persistently refused medications. The resident had multiple significant cardiac and metabolic diagnoses, including atherosclerotic heart disease, hypertensive heart disease with heart failure, cardiomyopathy, and type 2 diabetes mellitus, and was ordered 15 active medications (14 oral and 1 clonidine transdermal patch). Despite this complex regimen, the resident repeatedly refused most medications over an extended period, taking only the clonidine patch, while remaining alert, oriented, and frequently going out on pass with a family member. The resident’s care plan for medication refusal, initiated on 6/30/25 and revised on 7/29/25 and 10/14/25, contained only four original interventions: assess the reason for refusal, document refusals and actions taken, encourage medication compliance with explanation of risks and benefits, and notify the physician for complications. No new or modified interventions were added despite ongoing, documented noncompliance with medications. Physician notes over several months documented that the resident was noncompliant with blood pressure medications except the clonidine patch and remained noncompliant with medications and care despite education on risks. The electronic MAR for January 2026 showed the resident refused all medications except the clonidine patch for the entire review period. Interdisciplinary team (IDT) meeting notes showed that while the resident’s medication refusal was noted on 6/30/25, subsequent IDT meetings did not include discussion or reassessment of this issue. Nursing staff reported that when the resident refused medications, they provided education, documented the refusal, and informed the nursing supervisor, but the RN supervisor acknowledged there were no additional interventions or assessments beyond re-education and documentation. The RN supervisor also stated she had not contacted the pharmacist to investigate potential medication-related issues contributing to the refusals and had limited documented communication with the physician, with the last recorded contact several months earlier. The administrator stated she was not aware of the resident’s ongoing medication refusals. The facility’s own person-centered care planning policy required the IDT to prepare, review, and revise the comprehensive care plan and to implement interventions designed to meet resident objectives, which was not carried out in this case.
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