F0656

D

Failure to Update Care Plan for Repeated Care Refusals and Skin Risk

Austin, Texas Survey Completed on 01-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and update a complete, measurable care plan that reflected a resident’s refusals of showers and incontinence care, including associated skin assessments and interventions to reduce the risk of skin breakdown. Interview with the DON revealed she had been trained on completing care plans and stated that residents’ participation in ADLs and refusals of care should be included on the care plan and updated when new problem areas are identified. She acknowledged that Resident #1’s care plan did not contain risk, goals, or interventions related to the resident’s refusals of showers and changing briefs, and she stated she did not know why the care plan was not updated. She further stated that if something was not on the care plan, it could affect the quality of care and that not updating this resident’s care plan could increase the risk for skin breakdown and infection (UTI).

The ADM reported he was trained on care plans and that they should be person-centered, and that frequent refusals of services should be included so staff would know the resident refused. He stated the IDT was responsible for entering information into the care plan and that the DON monitored care plans for accuracy, although he did not know how she monitored revisions. The ADM reported that he had asked the DON to care plan this resident’s refusals back in September 2025 and did not care plan it himself. Record review showed that Resident #1, an 80-year-old female with diagnoses including cerebral infarction, chronic pain, depression, morbid obesity, altered mental status, hemiplegia, and hemiparesis, had a comprehensive care plan with ADL self-care performance goals, but the plan lacked revisions to address her ongoing refusals of showers and changing briefs, and the related skin and infection risk.