Failure to Develop Individualized Care Plans for Diabetes Management and Skin Protection
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents with identified needs. One resident was admitted with a diagnosis of diabetes and required insulin, but the comprehensive care plan did not include specific approaches or interventions for managing diabetes or insulin administration. This omission was confirmed by a licensed practical nurse/unit manager during an interview and was discussed with facility leadership during the exit conference. Another resident was admitted with peripheral vascular disease and a non-pressure ulcer of the left ankle, requiring assistance with personal care and interventions to prevent skin breakdown. Although the care plan included encouraging the resident to wear long pants to prevent injury, observations showed the resident repeatedly wearing short pants, with long pants available but not worn. Staff interviews indicated the resident often did not comply with wearing long pants, but the care plan lacked individualized approaches to address this non-compliance. These findings were confirmed through record review, staff interviews, and direct observation.