Failure to Assess Resident Competency and Staff Training for Blood Glucose Monitoring Device
Penalty
Summary
The facility failed to determine whether a resident was safe to self-monitor diabetic medication treatment results using a continuous blood glucose monitoring system (FreeStyle Libre 3). Observation and interview revealed that the resident used a sensor and handheld meter to check blood glucose levels and reported the results to nursing staff. The resident was not aware of when a manual blood glucose check would be necessary and was unfamiliar with the device's alarm functions. There was no evidence that the resident had been given guidance or assessed for knowledge on using the monitor or recognizing when to perform a manual check for accuracy. Further review showed that the resident's self-administration of medications assessment did not address the resident's competency with the device or provide any guidance. The assistant director of nursing confirmed that the facility lacked a policy or process for the use of the FreeStyle Libre 3 device and had not provided training or competency checks for nursing staff regarding its operation. Manufacturer instructions for the device require users to review all product instructions and complete tutorials, including understanding symbols that indicate when a manual blood glucose check is needed, but this was not ensured by the facility.