Failure to Develop and Implement Care Plan for Prednisone Use in Diabetic Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing the use of Prednisone for one resident with a history of diabetes mellitus (DM) and chronic obstructive pulmonary disease (COPD). Despite the known risk of Prednisone to increase blood sugar (b/s) levels and induce hyperglycemia, there was no care plan created to monitor for risk, side effects, or adverse reactions related to this medication. As a result, the resident's b/s levels were not monitored from 4/11/2025 through 5/16/2025, and no interventions were documented to ensure b/s remained within an acceptable range. This lack of monitoring and absence of a care plan led to the resident experiencing an altered level of consciousness, hypotension, high heart rate, and a b/s level too high to register on the facility's glucometer. The resident was subsequently transferred to a general acute care hospital, where she was diagnosed with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), requiring admission to the intensive care unit in critical condition. Facility policy required comprehensive, person-centered care plans with measurable objectives and monitoring for medication effects, but these were not followed in this case.