Failure to Care Plan Ongoing Refusals of Care and Noncompliance
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes addressing a resident’s repeated refusals of essential care. The resident was an elderly female with Alzheimer’s disease, dysphagia, muscle wasting and atrophy, and reduced mobility, admitted with a stage 2 pressure ulcer. Her MDS showed a BIMS score of 7, indicating severe cognitive impairment, and she required extensive assistance with ADLs including toileting, bathing, personal hygiene, and rolling in bed. Despite these needs, the existing care plan, initiated for ADL self-care performance deficit related to Alzheimer’s disease, did not include her ongoing refusals of eating, showering, wound care, medications, or her noncompliance with remaining positioned on her sides. Progress notes over several months documented multiple specific instances of refusal. The record showed repeated refusals of showers and bed baths despite attempts by hospice aides and nursing staff, with the resident becoming agitated when encouraged. Notes also reflected frequent refusals of meals and substitutes, with the resident sometimes eating less than 25% of meals or tightening her lips to avoid eating, and staff documenting education on the importance of nutrition. Staff also recorded that the resident’s responsible party reported a long-standing pattern of minimal breakfast intake. Additionally, there were multiple entries of the resident refusing medications on several dates, including refusals after repeated attempts. The documentation further showed that the resident refused wound care and repositioning intended to promote healing of her sacral pressure ulcer. Staff notes described having to beg the resident to allow dressing changes and peri care, with the resident limiting the time allowed for care, and refusing repositioning despite education about the impact on her bedsore. Interviews with the ADON, RN, MDS nurse, and administrator confirmed that the resident frequently refused to eat, shower, take medications, accept wound care, and remain on her sides, and that these behaviors and refusals were not incorporated into the care plan. Facility staff acknowledged that such refusals and noncompliance should have been care planned and that the facility’s own Comprehensive Care Plans policy required measurable objectives and timeframes based on identified needs, including documentation of alternative interventions as needed.
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