Failure to Document and Provide Diabetes Education to Resident
Penalty
Summary
Facility staff failed to accurately and completely document diabetes mellitus (DM) education in the medical record for one resident. The resident, who had a history of DM, hyperlipidemia, cerebral vascular accident without residuals, and hypertension, was found to be cognitively intact and required staff assistance with activities of daily living. During an interview, the resident stated she did not know why she was taking insulin, indicating a lack of understanding about her diagnosis and treatment. A review of the resident's chart with the Registered Nurse Supervisor revealed no documented evidence that education regarding the DM diagnosis was provided to the resident or her representative. The facility's process requires that new diagnoses be discussed in an interdisciplinary team meeting with the resident or representative, with documentation in the progress notes. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that documentation of education was missing, and facility policy requires that each discipline document relevant information in the resident's progress notes.