F0658

D

Failure to Care Plan for Bathing Refusals and Coordinate Transportation for Outside Urology Care

Fresno, California Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement person-centered care plans and follow policies related to resident refusals of care and referrals to outside services. For one resident with progressive neuropathy, type 2 diabetes mellitus, and congestive heart failure, the facility did not create a care plan addressing repeated refusals of showers and bed baths. Documentation on Skin Monitoring Comprehensive CNA Shower Review forms from late January through late February showed that the resident refused all nine offered showers and accepted only three bed baths, with several additional partial bed baths documented due to shower refusals. Despite these repeated refusals, the sections on the forms for charge nurse assessment, interventions, and forwarding to the DON were left blank, and the DON, RN, and LVN all confirmed there was no care plan in place for the resident’s ongoing refusal of bathing.

Staff interviews further confirmed that the resident frequently refused showers and bed baths and that the facility’s expectation was that residents receive bathing at least twice a week. LVN 1 stated that all residents should receive two showers or baths weekly and that a care plan should be started if a resident refused. RN 1 similarly stated that a care plan should have been developed for the resident’s repeated refusals. The DON reviewed the resident’s care plans and shower documentation and acknowledged that the resident had no care plan, past or present, addressing the refusal of showers, even though the facility’s policy on comprehensive person-centered care planning requires care plans to include services to be furnished and services not provided due to a resident’s exercise of the right to refuse treatment.

The deficiency also includes the facility’s failure to coordinate transportation for another resident’s outside urology appointment, as required by the facility’s policies on referrals to outside services and resident rights. This resident, who had a history of cerebral infarction with hemiplegia and hemiparesis, type 2 diabetes mellitus, major depressive disorder, urinary retention, anxiety disorder, and UTI, had a scheduled follow-up urology appointment to assess removal of a urinary catheter in preparation for discharge to an assisted living facility. The Social Service Director stated that the process for arranging transportation required nurses to place appointments on a calendar that Social Services used each morning to set up transportation. However, the Social Service staff member responsible for the calendar admitted that, although she was informed of the urology appointment at admission and told the nurse she would put it on the calendar, she forgot to do so. As a result, the resident did not have transportation and missed the appointment. The DON confirmed that the resident missed the appointment because transportation was not provided and that there was no care plan addressing transportation to outside appointments or ensuring the resident attended those appointments, despite facility policies stating that the Director of Social Services coordinates referrals to outside services and that the facility assists residents in exercising their rights, including arranging transportation and supporting participation in treatment decisions.

A professional reference from the American Nurses Association regarding the nursing process was also cited, stating that nursing care is implemented according to the care plan, that continuity of care must be assured, and that both the patient’s status and the effectiveness of nursing care must be continuously evaluated with the care plan modified as needed. This reference underscores that the facility’s failure to develop and implement appropriate care plans for the resident refusing showers and for the resident requiring transportation to an outside urology appointment was inconsistent with professional standards of nursing practice and the facility’s own policies on comprehensive person-centered care planning, referrals to outside services, and resident rights.