F0656

D

Failure to Care Plan Diabetes and Post-Fall Facial Fracture

Kingsland, Texas Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to develop and implement a person-centered comprehensive care plan that addressed all of a resident's medical, physical, mental, and psychosocial needs. The resident was an adult male admitted with multiple diagnoses, including Type 1 DM with kidney complications, sepsis, nontraumatic subarachnoid hemorrhage, hemiplegia and hemiparesis following cerebral infarction, acute bronchiolitis due to RSV, and orthostatic hypotension. The admission MDS documented a BIMS score of 09 (moderate cognitive impairment) and an active diagnosis of DM, with Section N indicating the resident received insulin injections five days a week. Despite this, the care plan initiated on 12/31/2025 only addressed an ADL self-care performance deficit related to confusion and a moderate risk for falls related to confusion, and did not include the resident's Type 1 DM or insulin use.

Record review showed active physician orders for Lantus (insulin glargine) 15 units subcutaneously once daily starting 12/28/2025 and Humalog (insulin lispro) per sliding scale before meals starting 12/29/2025 for DM management. These active insulin orders and the documented DM diagnosis were not reflected in the resident's care plan, meaning there were no care-planned interventions for blood glucose monitoring or insulin administration. The facility's own policy required that the comprehensive, person-centered care plan include measurable objectives and timeframes and describe services to meet the resident's physical, psychosocial, and functional needs, derived from the comprehensive assessment and completed no more than 21 days after admission.

In addition, the facility failed to update the care plan after the resident experienced a fall on 01/10/2026, was sent to the ER, and was diagnosed via CT maxillofacial imaging with a right-sided zygomaticomaxillary complex fracture. A progress note documented the resident's return from the ER with a diagnosis of facial fractures and no new orders, with a plan to continue monitoring, but this new condition was never added to the care plan. Interviews with the MDS nurse and Regional Nurse confirmed that the resident's comprehensive care plan was incomplete, that the DM diagnosis and facial fracture should have been care planned, and that the comprehensive care plan should have been developed and updated in accordance with facility policy and MDS triggers, but this did not occur.