Inaccurate Diabetes Care Plan Intervention Without Corresponding Insulin Order
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a person-centered comprehensive care plan consistent with the resident’s actual medical orders and needs. The facility’s policy required development and implementation of a comprehensive person-centered care plan for each resident, including identification and implementation of interventions and treatments to address physical, functional, and psychosocial needs, and updating the care plan with each MDS assessment and periodically. Record review for one resident with multiple diagnoses, including hypertensive heart and chronic kidney disease and diabetes, showed the last care plan review was completed on 12/21/25 and included an endocrine/diabetes care plan with an intervention for “High Risk Medications: Insulin per MD order,” initiated on 12/15/25. However, review of the resident’s medical record on 3/17/26 showed there was no physician’s order for insulin during the resident’s stay, and the DON confirmed the resident had not had an insulin order and that insulin should not have been documented on the care plan. This discrepancy between the documented care plan intervention and the absence of a corresponding physician order demonstrated that the facility did not maintain an accurate, person-centered comprehensive care plan for the resident, as required by its own care planning policy.
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