Failure to Document Fall and Monitor Diabetes Management in Two Residents
Penalty
Summary
The facility failed to document and monitor changes in condition for two residents. For one resident with Alzheimer's disease, a history of falls, and multiple comorbidities including a left femur fracture and impaired mobility, an unwitnessed fall occurred. The nursing note indicated the fall, but the nurse did not initiate the fall protocol or update the care plan as required. The facility's policy states that all falls, including those prior to or during admission, must be documented in the care plan, but this was not done for this resident. For another resident with diabetes who was receiving insulin therapy, the comprehensive care plan did not include indicators for identifying or preventing hypo- or hyperglycemia, despite physician orders for insulin administration and specific blood sugar monitoring protocols. The Assistant Director of Nursing confirmed that the care plan should have included these indicators. The facility's policy requires that acute or temporary problems be incorporated into the comprehensive plan of care, but this was not followed in this case.