Deficient Glucose Monitoring and Insulin Administration Practices
Penalty
Summary
The facility failed to ensure proper management and use of glucometer testing supplies and continuous glucose monitoring (CGM) systems for residents with diabetes. Surveyors found that glucometer testing solutions and test strips were not dated when opened, and expired supplies were not discarded according to manufacturer instructions. Staff were observed using control solutions and test strips beyond the recommended 90-day period after opening, and the required dating of these items was not consistently performed. Additionally, staff did not follow proper procedures for mixing and applying control solutions during calibration, and cleaning protocols for testing equipment were not adhered to as specified by the manufacturer. Nursing staff lacked adequate training and competency in the use of CGM systems and glucometers. Interviews revealed that staff had only received brief, informal instruction on CGM use, without review of manufacturer guidelines or formal documentation of competency. There were no records of staff training or competency assessments related to insulin administration, insulin pens, CGM systems, or glucometer calibration. Staff demonstrated inconsistent understanding of when and how to calibrate CGMs with glucometer readings, and there was confusion regarding the frequency and documentation of calibration checks. The Infection Control Coordinator and the DON confirmed the absence of training records and acknowledged that staff were not following established protocols. The facility also failed to ensure that insulin was administered or withheld in accordance with prescriber orders for a resident with diabetes. Medical records showed that insulin was sometimes given when blood glucose levels were below the physician-ordered threshold, and documentation was lacking when insulin was administered outside of prescribed parameters. The DON confirmed that staff should have followed physician orders and documented rationale when deviations occurred. These deficiencies affected all residents with diabetes in the facility, including those using CGM systems and those receiving insulin therapy.