Failure to Develop Baseline Care Plans for Diabetic Residents
Penalty
Summary
The facility failed to develop baseline care plans that included diabetes care and necessary interventions for four residents diagnosed with diabetes mellitus. According to the facility's policy, a baseline care plan should be developed within 48 hours of a resident's admission to address their immediate needs. However, the review of clinical records revealed that the baseline care plans for Residents R22, R32, R150, and R195 did not include diabetes care, despite their diagnosis. This omission was confirmed during an interview with the Director of Nursing and Assistant Director of Nursing. Resident R22 was admitted with a diagnosis of diabetes mellitus, but their baseline care plan, completed on January 11, 2025, did not address diabetes care. Similarly, Resident R32's care plan, completed on November 9, 2024, and Resident R150's care plan, completed on November 30, 2024, also lacked diabetes care planning. Resident R195 was not care planned within 48 hours of admission, and their care plan, completed on September 2, 2024, did not include diabetes care. These findings indicate a failure to provide effective and person-centered care for residents with diabetes, as required by the facility's policy and state regulations.
Plan Of Correction
Residents 22, 32, 44, 150, and 195 have been in the center greater than 48 hours. Their care plans were reviewed and care plans updated to reflect diabetes by the RNAC/designee. New admissions and readmissions have the potential to be affected. A review of residents admitted from 1/13/2025-1/17/2025 was conducted by the DON/designee to ensure baseline care plans included diabetes diagnosis. Corrections will be made as needed. To prevent recurrence, licensed nursing staff will be educated on the Interim Baseline Care Plan policy by the DON/designee. To monitor and maintain compliance, new admission and readmissions with diabetes will be audited by the DON/designee weekly x 4 weeks and monthly x 2 months to ensure baseline care plans include diabetes as appropriate. Results of the audits will be forwarded to the center QAPI committee for review and recommendations.