F0655

D

Failure to Develop Timely Baseline Care Plan for Diabetic Resident

Chico, California Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The facility failed to develop and implement an initial person-centered baseline care plan addressing diabetes within 48 hours of admission for one resident. Facility policy titled "Person-Centered Care Planning" required that a baseline care plan, including minimum healthcare information necessary to properly care for each resident and addressing resident-specific health and safety concerns, be developed and implemented within 48 hours of admission. Record review showed that the resident was admitted with diagnoses including diabetes, kidney disease, and depression, yet the initial care plan report created on 2/6/26 did not include a baseline care plan for diabetes care. A diabetes care plan was not created until 2/20/26, which was 15 days after admission.

Further record review of the resident’s eMAR showed that on 2/5/26 there was an order to notify the physician if the resident’s blood sugar level was 400 or greater. The eMAR documented blood sugar levels of 435 on 2/11/26 at 5:30 p.m. and 400 on 2/16/26 at 5:30 p.m. An alert note dated 2/11/26 at 8:22 p.m. documented that a licensed nurse administered medication as ordered and contacted the doctor for further orders after the 435 blood sugar reading. During an interview, the resident reported that prior to admission their blood sugar ranged from 55–200, but since being at the facility it had been between 300–500, and stated that no one had discussed the high blood sugars or what was being done to manage them. In a concurrent interview and record review, the DON and ADON confirmed that diabetes should have been included on the resident’s care plan and that the care plan should have been updated when the resident experienced high blood sugars that required physician notification.