Failure to Develop Baseline Care Plan for Insulin Use in Non-Diabetic Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident who was receiving insulin for hyperglycemia following admission. Upon review, it was found that the resident did not have a documented diagnosis of diabetes mellitus or hyperglycemia in the electronic health record, despite having an active order for insulin glargine administered twice daily. The resident's Minimum Data Set indicated insulin administration, but did not reflect a diagnosis of diabetes or hyperglycemia. Family interview confirmed the resident was receiving insulin, which began during a prior hospital stay, and the resident's blood sugars were reportedly stable. Further investigation revealed that the attending physician's admission note documented hyperglycemia as the reason for insulin therapy, with no history of diabetes. However, this diagnosis was not added to the resident's official list of diagnoses, nor was a baseline care plan created to address hyperglycemia or the use of insulin. The Interim Director of Nursing confirmed the absence of both the diagnosis and the baseline care plan for managing the resident's blood sugar levels.