F0656

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Failure to Care Plan Ongoing Medication Refusals for a Cognitively Impaired Resident

Brenham, Texas Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s repeated refusal of medications. The resident was a 70-year-old male admitted with acute kidney failure, pain in the left hand, and traumatic brain compression with herniation. His MDS comprehensive assessment showed a Cognitive Patterns score of 6, indicating severe cognitive issues. The existing care plan included a focus on impaired cognitive function with an intervention to administer medications as ordered and monitor for side effects and effectiveness, and a separate focus on the resident’s preference to receive one pill with a full container of pudding. However, there was no specific care plan focus or interventions addressing his ongoing refusal to take multiple prescribed medications.

Record review of the MARs for February and March showed that the resident refused numerous medications on multiple occasions, including fluticasone nasal spray, Lidoderm patches, sodium chloride nasal solution, atorvastatin, melatonin, Seroquel, apixaban, gabapentin, lamotrigine, levetiracetam, and sevelamer carbonate. Despite this pattern of refusals, the care plan was not updated to include measurable objectives, timeframes, or individualized interventions to address the refusals. The resident reported that he did not take medications he disliked because they made him feel sick and tasted terrible, and he believed he would get better on his own. He stated that his pain was there for a reason and that medications covered up the pain when there were severe problems.

Multiple staff interviews confirmed that medication refusals were not incorporated into the resident’s care plan. LVN A stated that medication refusals should be in the care plan and that she documented refusals in progress notes or the MAR but had not been asked to review care plans and had not done so. The interim part-time DON, who assisted with care plans, stated that medication refusal should be care planned and that everything a resident did had to go in the care plan, but acknowledged difficulties with documentation due to heavy reliance on agency staff. RN A, identified as responsible for care plans, stated that medication refusals should be care planned and that she relied on 24-hour reports and nurses’ input, but she was unsure if this resident refused medications and believed he would take them with pudding. Other nurses and aides reported hearing or observing the resident refuse medications, sometimes even when pudding was offered, and stated that such refusals should be care planned with interventions. The Administrator described the care plan as a blueprint of who the resident was and agreed that medication refusals should be care planned with interventions, but the resident’s care plan still lacked a specific problem and interventions for his repeated medication refusals, despite the facility’s written policy that care plans be used to guide daily care and be updated when changes in condition occur.

The facility’s care plan policy, “Using the Care Plan,” stated that completed care plans are to be used in developing residents’ daily care routines, must be available to staff responsible for providing care, and that changes in residents’ conditions must be reported so that assessments and care plans can be reviewed and updated. It also required that documentation be consistent with the resident’s care plan. In this case, although staff documented refusals on the MAR and were aware of the resident’s behavior and preferences regarding medication administration, this information was not translated into a comprehensive, person-centered care plan with measurable goals and interventions specifically addressing the ongoing medication refusals, leading to the cited deficiency.

The physician reported he did not remember being informed that the resident was refusing medications and stated that if a resident repeatedly refused medications, he would want to know and that the facility should care plan such refusals. Agency nurses reported limited familiarity with the resident and inconsistent use or review of care plans. Overall, the deficiency arose from the facility’s failure to integrate known, ongoing medication refusals into the resident’s care plan, despite multiple staff recognizing that such refusals should be care planned and despite a facility policy requiring care plans to reflect changes in condition and guide care and documentation.