Failure to Care Plan for Ongoing Refusals of Care and Treatment
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address one resident's repeated refusals of care, treatment, and participation in a care conference. The resident was admitted with multiple significant diagnoses, including chronic kidney disease stage 3B, asthma, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, essential hypertension, PTSD, and type 2 diabetes mellitus. A PT evaluation dated 11/25/25 documented that the patient was refusing any skilled services and identified a risk for falls due to physical impairments and functional deficits. Progress notes from 11/25/25 through 12/20/25 showed ongoing refusals of morning medications, a request not to be disturbed, refusal of a blood draw, and refusal to participate in a care conference. During interviews and concurrent record reviews, an LN confirmed that these refusals required a care plan with effective interventions to encourage acceptance of care, treatment, and participation in care planning, but acknowledged that no such care plan existed for this resident. The DON stated that nursing staff were expected to assess residents who refused care and treatment and initiate a care plan to address refusals and implement appropriate interventions to prevent potential health decline. Facility policies on refusing care and on comprehensive, person-centered care plans required the interdisciplinary team to assess needs, offer alternative treatments when appropriate, and develop measurable objectives and timetables to meet residents' physical, psychosocial, and functional needs, with care plans used to guide daily care routines. Despite these policies, the resident's refusals were not incorporated into a written care plan, which, according to staff, placed the resident at risk for worsening underlying conditions, overall health decline, and preventable complications.
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