Failure to Monitor and Support Resident's Continuous Glucose Monitoring System
Penalty
Summary
The facility failed to provide necessary care and services for a resident with type 2 diabetes by not monitoring the resident's continuous glucose monitoring (CGM) system and not ensuring that CGM sensor patches were available for application as ordered by the physician. Documentation showed that on multiple occasions, the required CGM sensor patches were not available in the facility, and staff did not apply the sensors as ordered. Instead, the resident independently applied the CGM sensor patches every 14 days without staff assistance, despite not having requested self-administration of medication. Licensed staff did not monitor the placement or functionality of the CGM system, and the Director of Nursing was unaware of the resident's use of the CGM sensor until it was observed during the survey. Additionally, the facility did not complete the resident's Admission/Readmission Screen and Baseline Care Plan form accurately upon admission. The assessment was left incomplete and unsigned, and it did not address the resident's use of a CGM system. The lack of a comprehensive, person-centered care plan meant that there were no documented goals or interventions for monitoring the resident's CGM sensor, as required by facility policy. The MDS Coordinator confirmed that the absence of a complete assessment and care plan could result in a lack of necessary care and services for the resident. Interviews with nursing staff revealed that the physician's order for the CGM sensor was received and processed, but no additional order for monitoring the device was obtained. Staff acknowledged that the resident's ability to self-administer the CGM sensor was not properly assessed, and the facility did not ensure the availability of sensor patches. Facility policies reviewed indicated that all services and changes in resident condition should be documented, and that comprehensive, person-centered care plans should be developed and implemented for each resident.