Failure to Implement Person-Centered Cardiac Care Plan Interventions
Penalty
Summary
The facility failed to implement person-centered interventions for a resident with significant cardiac diagnoses following admission. The resident, who was cognitively intact and had recently undergone surgical repair of spinal stenosis, had multiple cardiac conditions including atrial fibrillation, early ventricular depolarization, atherosclerosis of the aorta, bilateral carotid artery stenosis, and hypertensive heart disease. The admission care area assessment (CAA) identified the need for monitoring, medications, and treatments for these cardiac conditions, as well as for a pacemaker, but did not specify any person-centered interventions tailored to the resident's needs. Interviews with facility staff, including an LPN, RN, and the DON, confirmed that while a generic care plan was auto-generated upon admission, no resident-specific interventions were entered within the required 48-hour timeframe. The facility's policy requires the interdisciplinary team to create an individualized care plan with specific interventions within 48 hours of admission, but this was not completed for the resident in question. Staff acknowledged that the resident's significant cardiac history and recent surgery warranted individualized interventions, such as ongoing blood pressure and vital sign monitoring, medication parameters, and monitoring for cardiac symptoms, none of which were documented in the care plan.