Failure to Follow Care Plan for Resident’s Refusal of Personal Care
Penalty
Summary
The facility failed to implement a comprehensive care plan that addressed an individual resident’s assessed needs and documented preferences. Clinical record review showed that the resident had chronic pain syndrome, major depressive disorder, and anxiety, and the Minimum Data Set dated November 6, 2025 indicated the resident was alert and oriented, reported feeling down, depressed, or hopeless several days per week, and was dependent on staff for personal hygiene. The resident’s care plan documented that she often refused care due to personal preference and directed staff to postpone the activity if she refused. However, the resident reported that staff cut her hair and took her for a shower even though she refused, and the Director of Nursing confirmed that staff provided the hair cutting and shower on January 6, 2026 despite the resident’s refusal. There was no documented evidence that staff postponed these activities in accordance with the resident’s care plan.
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