F0657

D

Failure to Implement Diabetes Management Parameters and Individualized Fall Interventions

Mcpherson, Kansas Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement appropriate care planning and clinical parameters for a resident with diabetes mellitus. One resident with a documented diagnosis of diabetes had an admission MDS showing intact cognition and dependence on staff for toileting hygiene, mobility, and transfers, and received daily insulin. The resident’s care plan directed staff only to provide a nighttime protein snack to keep blood sugars even and did not include any further direction related to diabetes management. A physician order required blood sugars to be obtained before meals and at bedtime for diabetes, but the medical record did not contain any blood sugar parameters. A licensed nurse confirmed there were no parameters and stated he would use his own nursing judgment to decide when to notify the physician, and a CMA reported not knowing what the parameters should be, noting that parameters had existed in a prior computer system but were absent in the new one. An administrative nurse stated the resident should have physician-ordered blood sugar parameters and that the care plan should direct staff on what to monitor for regarding the resident’s diabetes.

The deficiency also includes failure to implement individualized fall interventions for another resident with dementia, anxiety, repeated falls, and severely impaired cognition. This resident was dependent on staff for ambulation, toileting hygiene, and lower-body dressing, and required substantial assistance for mobility and supervision with transfers. The admission MDS documented that the resident was at risk for falls, had no functional impairment, and had experienced two or more falls since admission. The care plan instructed staff to determine and address causative factors of falls, provide exercise and strength-building activities, obtain a PT consult for strength and mobility, and request a pharmacist medication review, but did not include specific, individualized fall interventions beyond these general directions.

Multiple fall assessments and investigations documented that the resident was at high risk for falls and had several episodes of being found on the floor after scooting herself in her room, often near the room door, with falls described as unwitnessed and without injury. Immediate interventions documented in the fall investigations included obtaining a fall mat and placing signs in the room to remind the resident to call for help before attempting to transfer. Observations showed the resident in a low bed with a fall mat, able to stand with a gait belt and ambulate steadily with a walker, and staff reported she had numerous falls in her room, wore a Wander Guard that alarmed frequently, and was often placed in a recliner in the dayroom so staff could watch her. An administrative nurse stated that the resident had many falls in her room and that staff should have put interventions in place for those falls, and further confirmed that all the incidents where she scooted on the floor in her room were considered falls. The facility’s Resident Care Plan policy required evaluation by the interdisciplinary team, initiation of a care plan within 48 hours of admission, and review and revision of the care plan when resident needs changed, but the documented care plans did not reflect individualized interventions for the resident’s repeated falls.