Lack of Policy and Oversight for Continuous Glucose Monitoring Device Use
Penalty
Summary
The facility's Medical Director failed to ensure the adequate implementation of resident care interventions and policy review regarding the use of a continuous glucose monitoring device for a resident. Upon admission, the resident was prescribed a continuous glucose monitoring device to monitor blood glucose levels without finger sticks, which the resident preferred due to pain in the fingertips. However, the device was discontinued shortly after being ordered, despite the resident and family expressing dissatisfaction with reverting to finger sticks. Medical record review confirmed the device was ordered and used for approximately 2.5 days before being removed. Interviews with facility staff revealed that there was no existing policy for the use of continuous glucose monitoring devices, as the facility typically associated such devices with home settings. The Medical Director communicated to the provider that the device could not be used in the facility, but there was no formal or documented education provided to staff or other providers regarding this decision. Additionally, there was no documentation of a policy or procedure being developed for the use or non-use of such devices, nor any formal education following the Medical Director's awareness of the device's use in the facility.