Failure to Update Care Plans for Residents Using Continuous Glucose Monitoring
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflected the current status and needs of two residents. For one resident with diagnoses including hypertension, depression, and diabetes, physician orders indicated the use of both fast-acting and long-acting insulin, as well as a continuous glucose monitoring system (Libre). However, the resident's care plan did not include interventions or documentation related to the use of the Libre system, despite its active use as ordered by the physician. Similarly, another resident with atrial fibrillation, hypertension, and type 2 diabetes mellitus was prescribed insulin and also utilized a Libre continuous glucose monitoring system with self-checks. The care plan for this resident also failed to address the use of the Libre system. These omissions were confirmed by both the Nursing Home Administrator and the Director of Nursing during interviews, who acknowledged that the care plans were not updated to reflect the residents' current needs as required by facility policy and regulatory standards.