Failure to Ensure Timely Cardiology and Pacemaker Checks
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of practice for a resident with Alzheimer's disease, atrioventricular heart block, and a cardiac pacemaker. The resident's clinical record did not contain current physician orders for a cardiology consult or pacemaker checks, despite the presence of a remote telephonic pacemaker check device at the resident's bedside. The last documented pacemaker remote check was completed several months prior, and the care plan for the pacemaker had not been revised since July 2022. The Director of Nursing (DON) acknowledged the oversight after being informed of the issue. The DON discovered that the cardiology office had sent appointment letters to an incorrect address and had not listed the facility as the primary contact for the resident. Consequently, the resident missed the scheduled yearly cardiology appointment and the three-month remote pacemaker checks. The cardiology office confirmed that the pacemaker was still transmitting data but had not alerted the facility to any issues due to the contact information error.
Plan Of Correction
1. R24's yearly pacemaker appointment has been scheduled. 2. Facility will audit pacemaker orders and appointments on other residents to identify any baseline opportunities for missed pacemaker checks and/or annual appointments. 3. A Binder will be kept at the nurse's station with all residents that have pacemakers to ensure yearly appointments and regular checks are not missed going forward. 4. DON or designee will provide education to nursing staff on reviewing all pacemaker orders to ensure they are entered correctly, and appointments are made accordingly. 5. An audit will be conducted by DON or designee monthly x 3 months on all cardiac pacemakers to ensure remote checks are taking place and that yearly appointments are made. 6. Results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.