Failure to Care Plan for Care Refusals and Hand Contracture
Penalty
Summary
Surveyors identified a failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents. For one resident, a male with diabetes, seizure disorder, history of TIA, and cerebral infarction, the quarterly MDS showed severely impaired cognition (BIMS score of 5) and a care plan for ADL self-care deficits requiring supervision to limited assistance for personal hygiene. However, the care plan did not address the resident’s pattern of refusing care, including nail care. Observations showed the resident in bed with covers over his head and significantly overgrown fingernails on both hands, despite the resident stating that he had people who cut his nails and indicating he wanted his fingernails cut before again covering his head. Interviews with staff revealed an ongoing pattern of care refusals by this resident that were not reflected in the care plan. An RN reported asking the resident several times for permission to cut his fingernails, with the resident refusing and pulling covers over his head each time. A CNA similarly reported that the resident refused offers for nail care and showers and would always pull the covers over his head. The ADON stated it was normal for this resident to refuse all care, including nail care, and acknowledged that the refusals had not been documented or care planned, despite her belief that refusals should be care planned so staff would understand how to care for the resident. The MDS Coordinator stated she was not aware of the resident’s care refusals, including nail care, and confirmed that nursing staff were responsible for updating care plans or notifying her of issues. For the second resident, an older female with non-Alzheimer’s dementia, reduced mobility, muscle weakness, and a BIMS score of 5 indicating severely impaired cognition, the quarterly MDS and care plan did not reflect the presence of a right-hand contracture. Observation showed the resident’s right hand was contracted, and she was unable to open it, with no device in place for contracture management. Nursing staff and the Director of Rehabilitation confirmed the resident had a right-hand contracture, that therapy had worked with her, and that a splint had been tried but the resident would remove it and complain. The ADON stated the resident had been admitted with the contracture and that there should have been a care plan addressing it, and the MDS Coordinator acknowledged she was unaware of the contracture and that the care plan should have included the contracture, its care, and the resident’s refusals to keep the splint in place. The facility’s policy required a comprehensive person-centered care plan with measurable objectives and timeframes to meet residents’ identified needs, which was not followed in these cases.
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