Failure to Develop Person-Centered Care Plans for Diabetes and Smoking
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents in the areas of diabetes management and smoking status. For one resident with a diagnosis of diabetes and moderate cognitive impairment, there were active physician orders for insulin glargine and metformin, yet the care plan did not address diabetes management. The MDS quarterly assessment confirmed the diabetes diagnosis and use of hypoglycemic medication, but the MDS Nurse, responsible for care planning, acknowledged during an interview that a diabetes care plan had never been implemented and that this omission was missed during the comprehensive review. The DON confirmed that the MDS Nurse was responsible for ensuring care plans for medical diagnoses were in place. For another resident, who was cognitively intact and assessed as a safe smoker requiring assistance to go outside to smoke, the care plan did not address smoking status. The MDS Nurse, during a review and interview, confirmed that no smoking care plan had been implemented for this resident. Both the DON and the Administrator stated that the MDS Nurse was responsible for ensuring care plans reflected residents' needs, including smoking status. These findings were based on observations, record reviews, and staff interviews.