Failure to Document and Maintain Pacemaker Information in Medical Records
Penalty
Summary
The facility failed to obtain and document essential information regarding residents' pacemakers, including the make, model, and serial number, as well as ensuring that this information was readily available in the residents' medical records. For five residents with pacemakers, medical records, progress notes, admission assessments, and care plans did not include the required pacemaker details. In several cases, it was also unknown when the pacemaker was last assessed, and physician orders for pacemaker checks were either missing or incomplete. The facility's own policy requires documentation of the pacemaker's make, model, serial number, date and place of insertion, and specific orders for monitoring, but these requirements were not met for the affected residents. Interviews with facility staff, including the DON, confirmed that obtaining pacemaker information is challenging, with difficulties in acquiring details from residents, families, and cardiology offices. Despite these challenges, the admission nurse and DON are responsible for attempting to gather this information, but the records reviewed showed consistent omissions. The lack of documentation and clear orders for pacemaker monitoring was observed across all five residents reviewed for this issue.