Failure to Include Diabetes Mellitus in Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
The facility failed to develop a baseline care plan that included necessary instructions for effective and person-centered care for a newly admitted resident with multiple diagnoses, including type 2 diabetes mellitus with diabetic chronic kidney disease and heart disease. Upon admission, the resident's baseline care plan assessment did not indicate the presence of diabetes mellitus, as the corresponding box was not checked by the admitting nurse. As a result, the baseline care plan did not include interventions or care planning for diabetes management, despite the resident's documented diagnosis and need for oral antidiabetic medication and glucose monitoring. Interviews with facility staff revealed that the admitting nurse was aware of the resident's diabetes diagnosis but inadvertently failed to select the appropriate option in the electronic assessment, which led to the omission of diabetes-related care planning. The process for developing baseline care plans involved the admitting nurse completing the assessment, followed by review and sign-off by an RN, and a final review by the MDS Coordinator. However, the error was not identified during these reviews, resulting in the resident's baseline care plan lacking critical information regarding diabetes care. The deficiency was identified through record review and staff interviews, which confirmed that the baseline care plan did not reflect the resident's admitting diagnosis of diabetes mellitus. The facility's policy required completion and implementation of a baseline care plan within 48 hours of admission to promote continuity of care and resident safety, but this was not achieved in this instance due to the oversight during the admission process.