F0656

J

Failure to Timely Care Plan and Manage Refusals for Stage 3 Pressure Ulcer

Floresville, Texas Survey Completed on 01-04-2026

Penalty

Fine: $21,645

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames for a resident who had a stage 3 pressure ulcer. The resident, who had diabetes, morbid obesity, and severe protein-calorie malnutrition, was cognitively able to make decisions and was at risk for pressure ulcers. A stage 3 pressure ulcer on the resident’s left buttock was identified by the Wound Care NP on 11/20/2025, but the facility did not create a corresponding care plan until 12/31/2025, 41 days later. When the care plan was finally created, it incorrectly documented the wound as being on the right buttock instead of the left and did not include interventions addressing the resident’s ongoing refusals of skin assessments and wound care.

In the weeks leading up to and following the identification of the reopened stage 3 pressure ulcer, the resident repeatedly refused skin assessments and wound evaluations by the DON, charge nurses, and the Wound Care NP. Weekly body skin checks and wound progress notes documented multiple refusals from late October through the end of December, including refusals to allow assessment of an open area first reported by a CNA on 10/26/2025. Despite these repeated refusals and the presence of a known stage 3 pressure ulcer on the left buttock as of 11/20/2025, the resident’s care plan was not updated in a timely manner to reflect the wound, its correct location, or specific, person-centered interventions to address the refusals and associated risks.

On 12/24/2025, staff discovered maggots in the resident’s stage 3 pressure ulcer and in fecal material during a bed bath after the resident had refused incontinent care and wound care for days. CNAs and LVNs reported that the resident frequently refused to be checked, changed, showered, or to receive wound care, often telling staff to leave him alone, turning his face to the wall, or ceasing communication. Nursing notes documented multiple instances where the resident refused wound care, personal hygiene, and bed baths, even after education on the importance of clean, dry skin and wound care. Although the Wound Care NP and physician were notified of the refusals and the presence of maggots, the facility’s care plan still lacked timely, accurate, and comprehensive interventions addressing the resident’s wound, its correct site, and his persistent refusals of care, leading surveyors to identify a failure to develop and implement a comprehensive person-centered care plan consistent with the resident’s assessed needs.

Interviews with facility leadership and staff further confirmed that the care plan for the stage 3 pressure ulcer was not created or revised when the wound reopened and that refusals of care were not incorporated into the care plan during the period when the wound was present and worsening. The DON and Administrator acknowledged that delays in revising care plans could result in staff not knowing what to implement for the resident and that the resident might not receive the care outlined in the plan. The MDS nurse stated that care plans were generally reviewed quarterly unless there was a change in the resident, and confirmed that the care plan for the stage 3 pressure ulcer was not revised until 12/31/2025, despite the resident’s history of refusing showers, incontinent care, and wound care. The facility’s own policy required ongoing assessment and timely revision of care plans as residents’ conditions changed, but this process was not followed for this resident’s pressure ulcer and refusal behaviors, resulting in the cited deficiency.

Removal Plan

• Immediately update Resident #1's care plan to address refusal of skin assessments, refusal of wound treatment, and associated risks related to pressure injury deterioration and infection, including person-centered measurable interventions for refusal management, education, monitoring, and escalation.
• Have nursing leadership review the updated care plan with staff to ensure awareness and implementation.
• Provide in-service education for licensed nurses on F656 person-centered care planning requirements, incorporating care refusals into care plans when refusals impact medical/nursing needs, and ensuring care plans include measurable objectives, timeframes, and specific interventions.
• Provide in-service education for licensed nurses and CNAs on proper management and documentation of refusal of skin assessments and wound treatment, required escalation/notification when refusals place a resident at risk, and balancing resident rights with professional standards of care and safety.
• Reinforce a care plan review process requiring care plans to be updated when refusals of treatment/assessment are ongoing, a resident's clinical condition changes, or identified risks increase due to refusal behavior.
• Prevent staff from working until education and competency is completed.
• Incorporate the education into new hire onboarding.
• Implement a defined refusal process: CNAs notify the licensed nurse; the licensed nurse assesses, educates on risks, documents refusal, and notifies charge nurse and DON/designee for high-risk refusals; notify the physician when refusals impact ability to assess/treat conditions requiring medical oversight.
• Assign responsibility for updating the care plan to the licensed nurse in collaboration with the interdisciplinary team, with DON/designee oversight to ensure timely completion and implementation.
• Maintain continuity by updating care plans as long as refusals persist or risks remain, revising based on changes in condition, response, or acceptance of care.
• Monitor care plan updates through DON/designee routine audits and clinical oversight, including review of refusal documentation, care plan accuracy, and staff implementation.
• Provide refusal-of-care training to all direct care staff (licensed nurses and CNAs) covering identification, reporting, documentation, escalation, and implementation of person-centered interventions.
• Conduct weekly audits for four weeks, then monthly thereafter, of residents with pressure injuries and residents with documented refusals of care to verify refusals are reflected in the care plan, care plans include measurable objectives/interventions, and staff are implementing interventions as written; review results through QAPI and implement corrective actions as indicated.