Failure to Follow Physician Orders for Glucose Monitoring and Skin Checks
Penalty
Summary
The facility failed to ensure that care was provided in accordance with professional standards of practice for two residents. For one resident with type 2 diabetes, there were no physician's orders in place for the use of a continuous glucose monitoring (CGM) device, specifically the Freestyle Libre 2. Although the resident was using the CGM to monitor blood glucose and nurses were utilizing the device to guide insulin administration, the medical record lacked orders for the application, removal, and replacement of the sensor every 14 days, as well as for the use of the device to obtain blood glucose readings. Interviews with nursing staff, the nurse practitioner, and the Director of Nursing confirmed the absence of these required orders, despite the resident's ongoing use of the device for diabetes management. Another resident with chronic peripheral venous insufficiency and a history of impaired skin integrity did not have weekly skin check documentation as ordered by the physician. The care plan for this resident included monitoring for skin complications and documenting findings, but the last recorded weekly skin check was six weeks prior to the survey. Although the resident's legs were reportedly observed by staff during routine care, there was no documentation in the electronic health record to confirm that weekly skin checks were performed as required. These deficiencies were identified through observation, interviews, and record review, demonstrating that the facility did not consistently follow physician's orders or ensure complete and accurate documentation of care provided to residents with complex medical needs.