Failure to Develop Resident-Specific Diabetes Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident with type 2 diabetes mellitus. Upon admission and readmission, the resident's records indicated diagnoses including diabetes, hyperglycemia, gastrostomy, and dysphagia, with the resident being dependent on staff for multiple activities of daily living. The Minimum Data Set (MDS) assessment showed the resident had moderately impaired cognitive skills and was not prescribed insulin or any hypoglycemic medications. Despite this, the care plan initiated for the resident included interventions such as administering diabetes medications as ordered and monitoring for signs and symptoms of hyperglycemia and hypoglycemia, which were not applicable to the resident's current orders and condition. Interviews with nursing staff and review of the care plan revealed that the care plan was initiated before a full interdisciplinary team (IDT) care conference and did not accurately reflect the resident's needs or current medical orders. Staff confirmed that the interventions listed were not resident-specific and could cause confusion in care delivery. The facility's policy required the development of a comprehensive, person-centered care plan with measurable objectives and timeframes based on the resident's assessment, which was not followed in this instance.