F0656

D

Failure to Develop Care Plan for Resident’s Refusal of Care

Torrance, California Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to develop an individualized comprehensive care plan addressing a resident’s refusal of care and treatment. The resident was admitted with dementia and atrial fibrillation, and an MDS dated 1/5/2026 documented severely impaired cognition and a need for maximal assistance with toileting, bathing, and showering. Nursing documentation showed that on 11/15/2025 the resident refused to be showered, an IDT care conference note on 11/24/2025 recorded refusals of meals and medications, and a follow-up note on 12/26/2025 documented refusal of vital signs. Despite these documented refusals across multiple care areas, there was no corresponding care plan problem, goal, or interventions developed to address the resident’s refusal of care.

During an interview and concurrent record review on 2/20/2026, an LVN confirmed that there was no care plan in place for the resident’s refusal of care and stated that such a care plan should have been developed so staff would be aware of the resident’s needs and know how to respond appropriately. The LVN also stated that a care plan addressing refusal of care was important because the lack of one could place the resident at risk for skin breakdown and that the care plan serves as a communication tool for staff. In a separate interview, the DON stated that when a resident refuses care, a care plan should be developed to guide staff in directing care. The facility’s written policy on comprehensive care plans indicated that each resident’s care plan is to incorporate identified problem areas and associated risk and contributing factors, with interventions designed after consideration of the relationship between the resident’s problem areas and their causes, which was not followed in this case.