Failure to Care Plan Diabetes and Implement Listed Fall Mat Intervention
Penalty
Summary
Surveyors identified that the facility did not develop and implement a comprehensive care plan addressing all identified needs for a resident with multiple diagnoses. Record review showed the resident was an older female with a history of cerebral infarction and Type 2 diabetes with hyperglycemia, with an active diagnosis of diabetes mellitus documented on a recent quarterly MDS. Despite this, the resident’s care plan contained no problem, goals, or interventions related to diabetes, including no care plan direction for glucose monitoring, diet, or routine diabetic labs and diagnostic tests. The facility’s policy required the comprehensive care plan to describe services to attain or maintain the resident’s highest practicable well-being and to be reviewed and revised after each comprehensive and quarterly MDS assessment, but this was not done for the resident’s diabetes. The facility also failed to implement an existing intervention listed on the resident’s care plan. The resident had an ADL self-care performance deficit care plan initiated in 2022 that included floor mats as an intervention. During observation, surveyors noted there were no floor mats in the resident’s room while the resident was in bed. In interviews, the MDS nurse acknowledged that the fall mats on the care plan were supposed to have been removed because they were not being used, but the care plan had not been updated accordingly. The MDS nurse and the ADON both stated that the resident’s diabetes should have been care planned, including diet and labs, and that the MDS nurse typically updated the clinical aspects of the care plan.
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