Failure to Update Interdisciplinary Care Plan for Resident With Ongoing Refusals
Summary
The deficiency involves the facility’s failure to develop and maintain a timely, person-centered, comprehensive care plan and to ensure that it was reviewed and revised by an interdisciplinary team with resident and representative involvement. For Resident #1, a male with multiple complex diagnoses including metabolic encephalopathy, stroke, Type 2 diabetes, end-stage renal disease, cognitive communication deficit, dependence on renal care, and a left below-knee amputation, the care plan dated 1/1/26 addressed only wound care. The care plan documented pressure injuries to the right hip, right heel (stage 3), sacrum (stage 3), and an unstageable wound to the left BKA, but contained no additional information regarding other care needs. Despite the resident’s severe cognitive impairment (BIMS score of 6) and total or maximal dependence for most ADLs, the care plan was not expanded to address his broader clinical and behavioral needs. Record review showed extensive, ongoing refusals by the resident of medications, blood sugar checks, meals, ADLs, and wound care over a period of weeks, yet these refusals were not incorporated into the care plan. Progress notes documented repeated refusals of insulin, blood sugar checks, antibiotics, pain patches, and other medications on numerous dates, as well as refusals of meals and both meals and accuchecks during specific shifts. Wound care notes indicated that the resident sometimes allowed assessment but then refused completion of treatments, stating that wound care had already been done, and continued to refuse despite reorientation and education. Staff also documented that attempts to notify the family member (FM) were sometimes unsuccessful, and that the resident’s wounds showed decline, including increased redness and irritation in the gluteal folds, while refusals of wound care persisted. Interviews with staff revealed that the care plan was not updated to reflect the resident’s consistent refusals or his nutritional issues. The DON acknowledged that none of the refusals were documented in the care plan and attributed care plan updating primarily to the MDS nurse, who had resigned and taken time off during the resident’s admission. The WCN stated she was familiar with the resident’s multiple wounds and frequent refusals of care and that she contacted the FM to encourage cooperation. A CMA reported that the resident appeared very depressed, frequently said “not right now” to medications, and that she tried multiple strategies (pudding, soda, ice cream, soup) to facilitate medication administration, but he continued to refuse. The DSS stated she did not realize she was responsible for completing care plans and initially held care plan meetings without involving department heads. The DM reported she was not made aware of the resident’s meal refusals, and the RA stated the resident refused follow-up weekly weights after the admission weight. Facility policies required care plan meetings upon admission and after significant changes, and required care plan review and revision upon status changes, but these processes were not carried out for this resident’s ongoing refusals and nutritional concerns. The resident’s point-of-care documentation showed low meal intake and frequent non-occurrence of meals, yet this was not translated into care plan interventions. Nutrition task records indicated that on multiple days the resident consumed only 0–25% or 26–50% of meals, and on several days meal intake was marked as not occurring. The RA confirmed that after the initial admission weight of 185.5 lbs, the resident refused subsequent weekly weights, and no additional weights were documented. Despite these patterns, the dietician was not successfully contacted by surveyors, and the DM stated she had not been informed of the refusals. Staff interviews further showed that some CNAs and nurses were unaware of the full extent of the resident’s refusals, relying instead on verbal shift reports rather than an updated care plan. Overall, the facility did not revise the care plan to address the resident’s persistent refusals of medications, ADLs, meals, and wound care, and did not ensure interdisciplinary, resident, and representative participation in developing and updating a comprehensive, person-centered care plan as required by facility policy. The ADM and DON described that care plan completion was a shared responsibility between nurse management and the MDS nurse, with corporate support available in the MDS nurse’s absence, but this process did not result in an updated plan for this resident. The DSS acknowledged she had not been educated initially on completing care plans and did not involve department heads in early care plan meetings. The DON stated that care plans not being updated could affect how aides provided care, but indicated that staff relied on daily nurse communication instead. Facility policies on care plan revisions specified that upon identification of a change in status, the nurse should notify the MDS coordinator, physician, and resident representative, and that the IDT should collaborate on interventions and update the care plan accordingly. Despite clear documentation of significant changes and ongoing refusals in the record, these steps were not followed for Resident #1, resulting in a care plan that remained limited to wound care and did not reflect his current needs and behaviors.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
IDT Did Not Review Quarterly Care Plan Revisions: A resident with anoxic brain damage, pulmonary HTN, and paraplegia had quarterly MDS assessments completed, but no IDT care conferences were documented for an extended period while the care plan was revised multiple times. Interviews showed the CQAN said the quarterly care planning process included an IDT meeting and that the IDT significantly influenced the care plan, while the MDS Coordinator said she completed quarterly reviews even when no IDT had been held.
Failure to Offer Quarterly Care Conferences: A resident with depression, anxiety, chronic pain, and DM was not consistently offered or documented for quarterly care conferences. The EMR showed one conference note where the resident declined participation, but no evidence of any later conferences being offered, provided, or refused. The resident said she did not always know the plan of care, and the family member said she had not been invited in over a year and did not know what was going on with the resident’s care.
A resident with chronic respiratory failure with hypoxia and diabetes had physician orders for continuous O2 and compression stockings, but was observed without either in place. The care plan did not document the oxygen or compression stocking interventions, and the DON stated refusals also were not documented.
A resident with major depressive disorder, stroke-related weakness/paralysis, and anxiety had a care plan that did not reflect her PASRR positive status for mental illness or include PASRR-related interventions, even though records showed she had been receiving MI specialized services and attending quarterly PASRR meetings. The annual MDS was coded as no ID/DD-related PASRR condition, and staff including the MDS coordinators, DON, and Administrator acknowledged the care plan was inaccurate and should have been reviewed and revised by the IDT.
Care plan not updated for new insulin use and blood sugar monitoring. A resident with DM and intact cognition began receiving insulin and required BG monitoring, but the care plan did not reflect the new insulin regimen or monitoring needs. The MAR showed insulin orders, and a progress note documented BG checks before lunch and dinner. Staff stated the resident was a new diabetic and the care plan had not been updated to match the new diagnosis.
A resident’s CCP was not updated after an oxygen order changed from 3 LPM to 4-5 LPM, and two other residents’ CCPs did not reflect self-administration of medications. One resident with schizophrenia had multiple meds ordered for bedside storage or unsupervised self-administration, but the CCP had no related focus or interventions. Another resident with dementia and diabetes was observed self-administering insulin even though the CCP only addressed staff administration.
IDT Did Not Review Quarterly Care Plan Revisions
Penalty
Summary
The facility failed to ensure Resident #40’s comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after quarterly assessments. Resident #40 was admitted with diagnoses including anoxic brain damage, pulmonary hypertension, and paraplegia. The record showed an IDT care conference was completed in January 2026, and the resident later had a Significant Change Assessment on 2/2/26 and Quarterly Assessments on 3/9/26 and 6/7/26, but no other IDT care conferences were documented until 8/13/26. The resident’s care plan was revised multiple times between January 2026 and 8/13/26, including revisions on 2/12/26, 2/17/26, 2/22/26, 2/23/26, 2/25/26, 3/25/26, 4/6/26, 4/15/26, 4/21/26, 5/4/26, 5/13/26, 6/9/26, 7/30/26, 8/7/26, and 8/10/26. During interviews, the CQAN stated the quarterly care planning process included an IDT meeting and that the IDT significantly influenced the information incorporated into the quarterly care plan, while the MDS Coordinator stated she completed quarterly care plan reviews regardless of whether an IDT had been held. The facility policy stated comprehensive, person-centered care plans are based on resident assessments and developed by an IDT.
Failure to Offer Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure quarterly care conferences were provided or offered for one resident who was cognitively intact and did not exhibit rejection of care behavior. The resident’s quarterly MDS indicated diagnoses of major depressive disorder, anxiety, chronic pain, and diabetes. A progress note from 5/21/25 documented that a conference occurred without the resident or a resident representative in attendance, and the resident stated she did not want to participate. The EMR did not contain evidence that any other care conference was offered, provided, or refused after that date. During interviews, the resident stated she did not always know what the plan was and could not remember attending or being offered a care conference in a long time. The social worker verified that no care conferences were documented in the EMR since May 2025 and stated care conferences should be completed quarterly. The social worker also stated the resident was due for conferences in March and June 2026 and that the family member would have been invited. The family member stated she had not been invited to or attended a care conference in over a year and did not know what was going on with the resident’s care. The DON stated quarterly care conferences were expected and that if the resident declined to participate, the EMR would have evidence of the refusal. Facility policy required residents and their representatives to be invited at least two weeks in advance, and if not invited, an explanation had to be included in the medical record.
Care Plan Not Updated for Oxygen and Compression Stocking Needs
Penalty
Summary
The facility failed to ensure a resident’s care plan was revised to reflect current needs and interventions. The facility’s policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident, and that care plans are revised as resident information and conditions change. Resident #55 was admitted with multiple diagnoses including chronic respiratory failure with hypoxia and diabetes, and had physician orders for compression stockings to the right leg and continuous oxygen at 1-2 L/min via nasal cannula as tolerated. On 8/4/26, Resident #55 was observed in her room with a portable liquid oxygen unit on the back of her wheelchair and an oxygen concentrator at bedside, but she was not wearing oxygen or compression stockings. CNA #2 stated the resident did not have oxygen on and should have. Review of the resident’s care plan showed it did not document the use of oxygen or compression stockings. The DON stated the care plan had not documented the use of oxygen or compression stockings and should have, and that refusals should have been documented but were not.
Care plan not updated for PASRR-positive resident
Penalty
Summary
The facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for one resident with PASRR positive status for mental illness. Resident #2 was admitted and readmitted with diagnoses including major depressive disorder, stroke with hemiplegia and hemiparesis, and anxiety disorder. Her annual MDS dated 03/13/2026 showed a BIMS score of 10, indicating moderate cognitive impairment, and the MDS Section A1500 was coded as no ID/DD-related PASRR condition. However, record review showed she had been PASRR positive for mental illness since a Level 1 screening dated 07/24/2025 and had a PASRR Comprehensive Service Plan dated 08/27/2025 showing she received MI specialized services. The resident’s care plan updated on 07/08/2026 addressed antipsychotic medication use for major depressive disorder with monitoring and reporting interventions, but no care plan identified her PASRR positive status or included interventions related to PASRR services. During interviews, the resident and family stated she had been PASRR positive since admission, attended quarterly PASRR meetings, and received MI specialized services. MDS Coordinator A, MDS Coordinator B, the DON, and the Administrator all stated the care plan should reflect PASRR positive status and be reviewed and revised by the IDT, and they acknowledged the annual MDS and comprehensive care plan were not accurate.
Care plan not updated for new insulin use and blood sugar monitoring
Penalty
Summary
The facility failed to update the care plan for R36 when the resident began using insulin and required blood sugar monitoring. R36 had a diagnosis of diabetes mellitus, and the Quarterly MDS documented a BIMS score of 15, indicating intact cognition, with no insulin use listed on the medication list at that time. The Annual MDS later documented that R36 received seven days of insulin, but the care plan dated 06/27/2026 did not include information that the resident had started insulin or needed blood glucose monitoring. The MAR dated 06/28/2026 showed insulin orders for 10 units subcutaneously at bedtime with blood glucose checks and 14 units subcutaneously in the morning, and a progress note dated 07/16/2026 documented that blood sugar was to be checked before lunch and dinner. Administrative Nurse E stated that R36 was a new diabetic and the care plan had not been updated, and Administrative Nurse D stated that care plans should be updated when a resident has a new diagnosis. The facility policy on care plan revisions upon status change stated that the process was intended to provide a consistent review and revision of the care plan for residents experiencing a status change.
CCPs Not Updated for Oxygen Orders and Self-Administration Needs
Penalty
Summary
The facility failed to keep the Comprehensive Care Plan (CCP) updated for a resident with malignant neoplasm of the left bronchus or lung, chronic obstructive pulmonary disease, and chronic respiratory failure. The resident’s CCP still listed oxygen at 3 liters per minute via nasal cannula with a start date of 10/23/2025, while the active physician’s order reviewed on 7/21/2026 directed continuous oxygen via nasal cannula at 4 to 5 liters, with a start date of 5/23/2026. The Clinical Nurse Manager confirmed on 8/3/2026 that the CCP had not been updated when the oxygen order changed and should have been. The facility also failed to include self-administration of medications in the CCPs for two residents. One resident with schizophrenia had active orders for several medications that could be kept at bedside or were marked for unsupervised self-administration, including cough drops, Vicks VapoRub, saline mist, and Abreva, and was observed with cough drops on the bedside table while stating the medication could be kept in the room. The CCP contained no focus, goal, or interventions related to self-administration, and the CNM confirmed this omission. Another resident with unspecified dementia and type 2 diabetes mellitus had an order for insulin lispro injections, no order for self-administration, and a CCP that addressed insulin-dependent diabetes only with medication administration by staff; however, the resident was observed being handed an alcohol wipe and syringe and then self-administering insulin.
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