Failure to Develop and Implement Comprehensive Diabetes Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a diagnosis of Diabetes Mellitus. Clinical record review showed that the resident had intact cognition and was prescribed multiple diabetes medications, including insulin, and had experienced episodes of hyperglycemia resulting in emergency department visits for falls and dizziness. Despite these events and ongoing medication management, the care plan did not include a focus area, goals, or interventions related to diabetes management. Additionally, the diagnosis of Diabetes Mellitus was not entered into the electronic health record (EHR) under the diagnosis section until a month after admission, and there was no documentation or monitoring for signs and symptoms of hyperglycemia or hypoglycemia in the Medication Administration Record (MAR) or EHR. Staff interviews confirmed that the Director of Nursing expected diabetes to be addressed in the care plan from admission, with appropriate monitoring and documentation for related symptoms, but acknowledged these elements were missing. Policy review indicated that the facility's comprehensive person-centered care plan policy required identification of problems, needs, strengths, preferences, and goals, as well as how the interdisciplinary team would provide care, but these requirements were not met for this resident.