Federal inspectors found that Sharon Care Center staff never notified the physician or the resident's healthcare proxy when the woman refused the ordered medical interventions, violating the facility's own policies for reporting changes in condition.
The resident fought staff attempts to change her incontinence briefs and would only drink coffee, consuming about a quarter of her meals, according to a certified nursing assistant interviewed during the November inspection. The CNA said she managed to change the resident's briefs at least twice per shift despite the resistance.
A registered nurse told inspectors on November 25 that the outgoing nurse had informed her about doctor's orders for IV insertion and fluid administration due to the resident's decreased oral intake. But those orders hadn't been carried out because the resident refused.
The RN confirmed that lab orders had also gone unfulfilled. There was no documented evidence that either the physician or the resident's healthcare proxy had been informed about the refusal.
The facility's Director of Nursing acknowledged during a November 26 interview that when a resident consumes less than 50% of their meals, the physician must be notified after two to three meals. The DON confirmed that this resident had consumed less than 50% of her meals on October 28 and that her intake "progressively decreased several times after that."
Nobody called the doctor.
The DON confirmed that orders for IV insertion, IV fluid administration, and lab work for complete blood count, basic metabolic panel, urinalysis and culture had not been carried out. No documented evidence showed that the physician or healthcare proxy was ever notified about the resident's refusal of treatment.
The resident and her healthcare proxy were never invited to any of the interdisciplinary team meetings reviewed over the past year, the DON confirmed.
The facility's own policy, reviewed December 16, 2024, requires staff to "immediately inform the resident, consult with the resident's physician and/or NP, and notify, consistent with his/her authority, resident representative" when there is a significant change in physical, mental or psychosocial status.
The policy specifically covers "deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications" and situations requiring significant treatment alterations, including "a need to discontinue or change an existing form of treatment due to adverse consequences."
Another facility policy mandates that interdisciplinary care planning teams include "to the extent practicable, the participation of the resident and the resident's representative." The policy states that "every effort will be made to schedule care plan meetings at the best time of the day for the resident and family."
Federal inspectors cited the facility for failing to ensure that residents and their representatives were informed of changes in condition and involved in care planning decisions. The violation was classified as causing minimal harm or potential for actual harm to few residents.
The case illustrates how communication breakdowns in nursing homes can leave families uninformed about their loved ones' deteriorating condition. While the resident refused medical interventions, federal regulations require facilities to notify physicians and healthcare proxies about such refusals so informed decisions can be made about alternative care approaches.
The inspection found no evidence that anyone explored why the resident was refusing treatment or whether alternative approaches might have been acceptable. The facility's failure to follow its own notification policies meant that neither the doctor nor the healthcare proxy could weigh in on the situation as it unfolded over weeks.
The resident remained in soiled incontinence briefs between changes while consuming only coffee and a quarter of her meals, with no documented effort to involve her designated healthcare decision-maker in addressing the deteriorating situation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sharon Care Center from 2025-11-26 including all violations, facility responses, and corrective action plans.