Failure to Develop Care Plan for New Onset Diabetes and Insulin Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident with new onset diabetes who was receiving insulin therapy. According to facility policy, a person-centered care plan with measurable objectives and timetables must be developed for each resident to address their medical, nursing, mental, and psychological needs. The policy also requires the care plan to be reviewed and updated after significant changes in a resident's condition, readmission from a hospital, and at least quarterly. Review of the resident's clinical record showed an admission with diagnoses including stroke, high blood pressure, and GERD. A physician's order was present for daily subcutaneous insulin injections due to new onset diabetes, and quarterly and annual MDS assessments confirmed insulin use during the look-back periods. However, there was no evidence in the clinical record that a care plan had been developed to address the resident's diabetes or insulin therapy. The DON confirmed during interview that no such care plan was in place.