Failure to Include FreeStyle Libre Device Management in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing the care and management of the FreeStyle Libre 2 Sensor or Reader for four residents. Each of these residents had physician orders specifying the use and scheduled changes of the FreeStyle Libre device as part of their diabetes management. However, reviews of their care plans revealed that none included instructions or interventions related to the care and management of these devices, despite the orders being present in their clinical records. The residents involved had diagnoses including high blood pressure, diabetes, muscle weakness, heart failure, and arthritis. The deficiency was confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that the care plans for these residents did not reflect the required care and management of the FreeStyle Libre devices. This failure was found to be inconsistent with the facility's own policy on comprehensive person-centered care planning and relevant state regulations.