Failure to Develop and Implement Comprehensive Insulin Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan addressing insulin administration for a resident with type 2 diabetes mellitus. The resident was cognitively intact and required insulin daily, as documented in the medical record and Minimum Data Set (MDS) assessment. Despite physician orders for both scheduled and sliding scale insulin, the care plan did not include any goals, interventions, or documentation related to insulin use or the resident's preferences regarding which nurses could administer her insulin. Interviews revealed that the resident did not trust a specific RN and preferred certain nurses to administer her insulin. On at least two occasions, the resident did not receive her prescribed insulin because the preferred nurses were unavailable, and the assigned nurse did not administer the medication. The resident kept a personal record of missed doses, which was verified by staff. Facility leadership confirmed that no alternative approaches had been attempted to ensure consistent insulin administration and acknowledged the absence of a care plan addressing these issues.