Failure to Develop Comprehensive Care Plan for Resident with New Diabetes Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed all of a resident's needs. Specifically, for one resident with a complex medical history including a history of transient ischemic attack, cerebral infarction without residual deficits, bipolar disorder, morbid obesity, chronic pain syndrome, hemiplegia and hemiparesis, and diabetes, the care plan initiated did not include goals or interventions for diabetes. The diagnosis of diabetes was added to the resident's record after the resident was transferred to the hospital for evaluation of symptoms such as diaphoresis, thirst, blurred vision, headache, and elevated blood sugar levels, which were related to the new diagnosis of diabetes. Review of facility policy indicated that an individualized, interdisciplinary care plan should be initiated within 24 hours of admission and updated as needed to reflect changes in the resident's condition. However, despite the addition of diabetes to the resident's diagnoses, the care plan was not updated to include this new diagnosis. This deficiency was confirmed by the Nursing Home Administrator and the Director of Nursing during an interview.