Failure to Develop Comprehensive Diabetes Care Plan for a Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing diabetes mellitus for a resident admitted with type 2 DM and a history of myocardial infarction. The admission record showed the resident was admitted with type 2 DM, and the MDS dated 12/31/2025 documented the resident as alert, oriented, with good recall, and with an active diagnosis of diabetes. Facility policy required that areas of concern triggered during the resident assessment be evaluated and incorporated into an individualized comprehensive care plan with measurable objectives and timetables to meet medical, physical, mental, and psychosocial needs. Despite the diabetes diagnosis being triggered in the MDS, there was no corresponding diabetes care plan in place for this resident. During an interview and concurrent record review with the DON and the MDS nurse on 1/21/2026, the surveyor requested the resident’s diabetes care plan. Initial review of the Care Plan Report under "Diabetes Mellitus" showed no care plan. When the MDS nurse searched under "diabetes," a care plan was visible, but it was dated 1/20/2026 and had been created by the DON after she overheard the surveyor ask for the resident’s diabetes care plan. The DON acknowledged that the diabetes care plan she created was incomplete. The MDS nurse stated there was no indication why the care plan had not been developed when type 2 DM was triggered in the MDS and confirmed that care plans are the comprehensive plan of care for the resident and that, without the diabetes care plan, the resident’s care would be incomplete.
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