Failure to Notify Family and Physician of Resident's Repeated Refusals of Care
Penalty
Summary
The facility failed to notify a resident's family and physician of repeated refusals of ordered care and treatment. Facility policy on Refusal of Care and Treatment, dated 02/16/23, required staff to notify the physician when a resident refused ordered treatment or procedures and to notify the resident's responsible party unless the resident chose otherwise. Resident #8 had physician orders dated 10/08/25 for weekly weights for four weeks, a milk/soy protein supplement of 60 milliliters twice daily, and sodium bicarbonate 650 milligrams twice daily. An admission assessment dated 10/14/25 documented that the resident had severely impaired cognition with a BIMS score of 3 and diagnoses of obstructive uropathy and non-Alzheimer dementia, and that the resident did not reject care during the seven-day look-back period. Subsequent nurses' notes from 10/2025 through 11/2025 showed multiple refusals of ordered care by Resident #8, including repeated refusals of the protein supplement health shake on several dates, refusal to be weighed on one date, and refusals of both the protein supplement and sodium bicarbonate on multiple dates. The resident representative stated they were not notified of these refusals. CNA #4 and LPN #6 each stated that when a resident refused care, the nurse should document the refusal and notify both the family and the physician. When shown the nurses' notes, the DON acknowledged there was no documentation that the family or physician had been notified of Resident #8's refusals of care and confirmed that such notification should have occurred and been documented in the nurses' notes.
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