Failure to Include Diabetes Management in Baseline Care Plan
Penalty
Summary
Facility staff failed to develop a baseline care plan addressing diabetes and blood sugar monitoring for a newly admitted resident diagnosed with diabetes, acute/chronic respiratory failure, and a tracheostomy. Upon admission, the resident was assessed as not cognitively impaired and was dependent on staff for mobility, transfers, dressing, hygiene, toileting, and eating setup. The baseline care plan created at admission focused only on discharge planning and equipment needs, without including any interventions or monitoring related to the resident's diabetes or blood sugar levels. A physician's order for blood sugar checks before meals and at bedtime was present, but there was no evidence that the baseline care plan incorporated these orders or addressed diabetes management until several days after admission. Staff interviews confirmed that diabetes should have been included in the baseline care plan, and documentation review supported the omission. The deficiency was acknowledged by administrative staff, with no additional information provided prior to survey exit.