Failure to Develop Care Plan for Resident's Continuous Glucose Monitoring System
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan for a resident who was using a continuous glucose monitoring (CGM) system. The resident, admitted with diagnoses including type 2 diabetes mellitus, hypertension, and COPD, had intact cognitive skills and was prescribed hypoglycemic medication. Physician orders specified the application of a CGM sensor every 14 days for continuous blood sugar monitoring. Despite this, there was no care plan created to address the use, monitoring, or management of the CGM sensor. Interviews with the MDS Coordinator and the Director of Nursing confirmed that licensed nurses did not develop a care plan with goals and interventions for the resident's CGM sensor. Both acknowledged that the absence of such a care plan meant there were no documented strategies to ensure the sensor was applied properly or functioning as intended. Review of facility policy indicated that a comprehensive, person-centered care plan with measurable objectives and timeframes should have been developed and implemented for each resident, but this was not done for the resident in question.