Deficiencies in Wound Care and CGM Monitoring
Penalty
Summary
The facility failed to adhere to physician orders for wound care for two residents, resulting in deficiencies in their treatment. One resident, admitted with cellulitis, anxiety, and paranoid personality disorder, had physician orders for wound care on their lower extremities. However, the care plan did not include a management plan for cellulitis, and the resident reported changing their own dressing due to neglect by staff. Observations confirmed that dressings were not changed as per the schedule, and the Treatment Administration Record inaccurately indicated that treatments were administered. Another resident, re-admitted with angina pectoris, cardiomyopathy, and intracardiac thrombosis, also experienced a lapse in wound care. Physician orders required daily dressing changes for wounds on the right wrist and toes, but the resident reported that dressings were not changed as scheduled. Observations and staff interviews confirmed that the dressings were not updated, despite the care plan indicating that treatments should be administered as ordered. Additionally, the facility failed to monitor a continuous glucose monitoring (CGM) device for a resident with diabetes, anemia, and heart failure. The resident's care plan did not include management for the CGM device, and the facility lacked a policy for its use. The resident's glucose levels were monitored through their personal cell phone, and nursing staff were not alerted to alarms unless they were near the phone. Interviews confirmed that the facility did not have a system in place to ensure continuous monitoring of the CGM results, leading to a deficiency in care management.
Plan Of Correction
1. R213 physician orders are plan of care were updated to reflect use of continuous glucose monitoring device. R436 had leg dressings changed on 2/10/2025. Care plan for R436 was updated to reflect diagnosis of cellulitis. R812 had dressings changed on 2/10/2025. Policy has been developed for personal use of continuous glucose monitoring. 2. An audit was conducted of wound dressings on 2/10/2025 to ensure all dressings were completed according to physician order. No additional issues identified. An audit was conducted of residents utilizing continuous glucose monitoring. No additional issues identified. 3. Director of nursing or designee will in-service licensed staff on completing treatments as ordered, and ensuring residents who utilize continuous glucose monitoring devices have physician orders and plan of care for care of device and components. 4. Director of nursing or designee will audit 5 residents twice weekly for 2 weeks, then 5 residents weekly for 2 weeks, then 5 residents monthly for 2 months to ensure treatments are completed as ordered. Director of nursing or designee will audit new admissions for 30 days to ensure residents with orders for continuous glucose monitoring have appropriate orders and care plan. Audit findings will be shared with QAPI committee.