Failure to Assess and Care Plan for Resident-Owned Heart Monitor
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary services for a resident with a heart condition who brought a personal heart monitoring machine from home. Upon observation, the machine was found on the resident's bed, plugged in, and covered with a pillowcase. The resident reported using the machine daily to monitor her heart, but stated that facility staff did not assist with the care or functionality checks of the device. Review of the resident's medical records revealed no documentation of a physician's order for the heart monitor, no care plan addressing its use, and no assessment or documentation of the machine's presence or maintenance upon admission, despite the resident's diagnosis of heart failure. Interviews with facility staff, including an LVN and the DON, confirmed that they were unaware of the heart monitor at the bedside and acknowledged the absence of required documentation, orders, and care planning for the device. The facility's policy required adherence to manufacturer guidelines for resident-owned equipment, but this was not followed. The DON verified that a physician's order, care plan, and assessment should have been completed for the heart monitor when the resident was admitted.