Failure to Develop Person-Centered Care Plans for Diabetes and Post-Surgical Wound
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement person-centered care plans addressing all identified diagnoses and conditions for two residents. For one resident with a documented diagnosis of Type 2 Diabetes Mellitus, medical record review showed an onset date of 10/5/2017 and a MAR order to check blood sugar three times a week. Despite this established diagnosis and ongoing blood sugar monitoring, there was no corresponding care plan for Diabetes Mellitus. The DON confirmed that a care plan for this diagnosis could not be provided because it had not been completed and acknowledged that not having a care plan developed and updated based on the resident’s diagnosis and change in condition was an issue. The second resident was admitted status post surgical repair of the left femur, with a surgical site described as having Steri-strips and bruising per provider note. Review of the EHR showed that a person-centered care plan had not been initiated to address care of the surgical site, even though the resident was admitted with this condition and was being seen by the wound team for the surgical site. During interview, the DON stated that this resident should have had a care plan initiated for the surgical site. Staff interviews also clarified that the admitting nurse is responsible for the baseline care plan and that UMs are responsible for updating care plans based on the MDS, diagnoses, and any change in condition, but these processes did not result in care plans for the identified conditions for these two residents.
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