Failure to Care Plan for Refusal of Care and Assistance With Activities
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s refusal of care and need for assistance with activities. The resident, originally admitted with encephalopathy, epilepsy, and essential hypertension, had an MDS dated 1/5/2026 indicating severely impaired cognitive function and dependence on staff for multiple ADLs, including oral care, toileting, bathing, lower body dressing, and personal hygiene. Observations on 2/19/2026 and 2/20/2026 found the resident in bed, either asleep or watching television. A CNA reported that on 2/19/2026 the resident initially refused a shower, sometimes screaming when refusing in the past, but was later convinced to shower. The CNA also stated the resident did not want to participate in activities on 2/19/2026 and 2/20/2026, and acknowledged not informing the charge nurse of the resident’s refusal to participate in activities. During concurrent interview and record review, an RN confirmed there was no documentation in the prior 72 hours that the resident had been offered or had refused activities, despite the expectation that such offers and refusals be documented and that residents have the right to decline. The RN also confirmed that the resident did not have a care plan addressing refusal of care. Review of an Activities-Quarterly/Annual Participation Review dated 1/5/2026 showed the resident had very little participation in group activities due to physical limitations and that new interventions were to include assistance to and from group activities. However, the resident’s activities care plan dated 3/31/2026 did not include the intervention that assistance would be provided to and from group activities. The facility’s policy on comprehensive person-centered care plans required measurable objectives, timeframes, and inclusion of services not provided due to the resident exercising the right to refuse treatment, but these elements were not reflected in the resident’s care plan related to refusal of care and activity participation.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.