Failure to Develop and Implement Person-Centered Care Plan for ADL Assistance, Constipation, and Insulin Refusal
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to develop and implement a complete, person-centered care plan for a resident with multiple medical conditions, including sequelae of nontraumatic intracerebral hemorrhage, diabetes mellitus, generalized weakness, glaucoma, and poor vision. The resident was admitted with a controlled carbohydrate, no-added-salt diet and regular texture with thin liquids. The resident’s MDS showed intact cognitive skills for daily decisions but indicated the resident required maximum assistance from staff for all ADLs and was frequently incontinent of bowel and bladder. The care plan for ADLs, dated 11/10/2025, only stated that the resident required assistance with eating and did not specify what type or level of assistance would be provided, despite the MDS indicating a need for maximum assistance. The glaucoma care plan indicated encouraging independence with ADLs and assisting as needed, but did not clearly identify that maximum assistance with eating was required. Family Member 1 reported that the resident was visually impaired and that staff would deliver the food tray, verbally identify the items on the tray, and then leave the resident to eat independently. FM 1 also stated that some of the foods staff said were on the tray were not actually present. During interviews, LVN 1 and the MDS nurse confirmed that the MDS documented the resident’s need for maximum assistance with eating and that the ADL care plan did not include specific interventions describing the type of assistance to be provided during meals. The MDS nurse and the DON both acknowledged that the care plan for glaucoma and ADLs should have specified that the resident required maximum assistance from staff for eating and that the care plan should have been individualized with specific interventions. Surveyors also found that the facility failed to implement the resident’s care plan for constipation and failed to develop a care plan addressing the resident’s refusal of insulin glargine. The resident had PRN orders for bisacodyl suppositories every 12 hours as needed for constipation and milk of magnesia if no bowel movement occurred in three days. Bowel movement records showed no bowel movements on multiple dates, yet the MAR indicated that bisacodyl and milk of magnesia were not administered on those days. LVN 1 confirmed that the resident did not have bowel movements on those dates, that the ordered constipation medications were not given as specified, and that the care plan intervention to administer medications as ordered was not followed. Additionally, the MAR documented that the resident refused insulin glargine on two dates, but there was no corresponding care plan addressing this refusal. LVN 1, the MDS nurse, and the DON all stated that a care plan should have been developed for the resident’s refusal of insulin glargine, consistent with the facility’s policy requiring the comprehensive care plan to identify declined services, associated risks, and IDT efforts when a resident refuses treatment.
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.