Failure to Develop and Implement Individualized Care Plan for Resident with Diabetes and COPD
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan for a resident with multiple diagnoses, including Type 2 Diabetes Mellitus (DM) and Chronic Obstructive Pulmonary Disease (COPD). Upon admission, the resident was prescribed Glipizide for diabetes management, but the care plan did not include individualized interventions such as regular blood glucose monitoring or instructions to withhold Glipizide during periods of poor oral intake. Nursing staff did not document blood glucose checks from admission through discharge, despite the resident refusing several meals while continuing to receive Glipizide. This omission led to the resident experiencing severe hypoglycemia, as evidenced by a blood glucose level of 53 mg/dl, altered mental status, and subsequent emergency hospitalization. Additionally, the resident had a physician's order for continuous oxygen therapy and monitoring of oxygen saturation every eight hours or as needed for symptoms of dyspnea or cyanosis. The care plan included interventions to monitor for signs and symptoms of respiratory distress and to check oxygen saturation, but these interventions were not followed. There was no documentation of oxygen saturation checks for extended periods, and the resident's oxygen level was not monitored according to the physician's order or care plan. This failure resulted in the resident being found with an oxygen saturation of 86%, altered mental status, and requiring emergency transport to a higher level of care. Interviews with nursing staff and the Director of Nursing confirmed that the care plans were incomplete and not individualized to the resident's needs. Staff acknowledged that the lack of specific interventions and failure to follow physician orders contributed to the resident's significant change in condition, including hypoglycemia and hypoxemia, which necessitated hospitalization. Facility policy and professional references reviewed during the survey emphasized the requirement for person-centered, comprehensive care plans with measurable objectives and individualized interventions, which were not met in this case.