The failure left nurses without a roadmap for communicating medication refusals between shifts, federal inspectors found during an August complaint investigation.
LVN A told inspectors she had tried multiple times to give Resident #1 the antifungal powder, but the resident consistently declined. When asked about reporting the refusals, the nurse said she informed the physician but couldn't remember whether she told the Director of Nursing or Assistant Director of Nursing.
"She said possible negative effect of not care planning for medication refusals was that the condition for which the medication was prescribed could get worse," according to the inspection report.
The nursing supervisor explained that care plans serve as essential communication tools between staff members, particularly on weekends when fewer administrators are present.
"She said a care plan was a road map to the residents' life," the supervisor told inspectors. "She said if a resident was not taking medications, and the refusal was not care planned, it would not be communication to the staff. She said no one would know that the resident was not taking the medication except the person the resident made the refusal to."
Federal regulations require nursing homes to develop comprehensive, person-centered care plans that address each resident's specific needs and preferences, including their right to refuse treatment.
The Administrator acknowledged the facility's failure during her interview with inspectors. She confirmed that she had reviewed Resident #1's care plan and found no documentation of the medication refusals.
"She confirmed that she had looked at Resident #1's care plan and, as much as they talked about Resident #1 not taking her medications, Resident #1's refusal of her Nystatin Power should have been care planned," the report states.
The Administrator described the facility's system for updating care plans: nursing staff should report resident preferences, significant changes, or anything that could alter current care through 24-hour reports to the Director of Nursing or Assistant Director of Nursing. This information gets communicated to the interdisciplinary team and physician so changes can be made to reflect the resident's current status and needs.
But that system broke down in Resident #1's case.
The Administrator explained that care plans provide crucial guidance for the entire care team and physicians. "She said a possible negative affect of not care planning for medication refusals would be that it would be more difficult for the team and doctors to figure out how to care for that resident," according to the inspection.
LVN A admitted she didn't understand the facility's care planning system. "She said she did not know the facility system for care planning, and she did not have any additional information to add regarding not care planning for medication refusals," inspectors wrote.
The Director of Nursing was unavailable for interview because she had left the facility due to illness. Inspectors called and left voicemail and text messages but received no response.
The facility's own policy emphasizes the importance of comprehensive care planning. According to the January 2023 policy document, care plans must include "measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs" and describe services that are not provided "due to the resident exercising his or her rights, including the right to refuse treatment."
The nursing supervisor stressed that responsibility for care plans ultimately rests with the Director of Nursing, though the MDS Coordinator and Assistant Director of Nursing contribute to the process.
She emphasized that medication refusals require immediate attention and care planning. "She said if a resident declines to take medication the resident's refusal of the medication should be reported to the DON and ADON and the refusal of the medication should be care planned."
Without proper documentation and care planning, staff members working different shifts remain unaware of residents' medication refusals, potentially compromising continuity of care and treatment decisions.
The breakdown in communication around Resident #1's repeated refusal of her prescribed antifungal medication illustrates how administrative failures can affect daily nursing care, leaving staff without the guidance they need to provide appropriate, individualized treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lily Springs Rehabilitation and Healthcare Center from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
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