Failure to Ensure Staff Competency in Use of Continuous Glucose Monitoring Device
Penalty
Summary
The facility failed to ensure that nursing staff were competent in the use of a continuous glucose monitoring device (FreeStyle Libre 3) for a resident with diabetes. The resident required assistance with activities of daily living and had multiple diagnoses, including diabetes, heart failure, respiratory failure, and mental health conditions. The resident's care plan required blood glucose monitoring three times daily and insulin administration based on those readings. Documentation showed the resident's blood glucose levels fluctuated widely, but there was no evidence that staff had received training or demonstrated competency in using the device. Interviews with nursing staff revealed that some had prior experience with similar devices at other facilities but had not received training or completed competency assessments at this facility. Staff were unaware of the location of manufacturer instructions, and the assistant director of nursing confirmed there was no policy or process for the use of the device, nor had any training or competencies been completed. The resident reported relying on staff to interpret her blood sugar readings and was not familiar with when a manual check was needed or how device alarms functioned. The administrator acknowledged that staff should be trained and competent in the use of medical equipment for resident care.