Failure to Follow LVAD Care Orders and Monitoring Protocols
Penalty
Summary
The facility failed to consistently implement prescribed treatments and assessments for a resident with a Left Ventricular Assist Device (LVAD). The resident was observed with an undated dressing on the LVAD site, and reported that the dressing was not being changed daily as required, leading to concerns about infection and pain. Staff interviews revealed confusion regarding the frequency and type of dressing changes, with some staff using dry kits instead of the ordered sterile wet kits, and a lack of appropriate supplies on the unit. Documentation showed multiple missed dressing changes and incomplete monitoring of the LVAD and vital signs as ordered by the LVAD clinic. The resident had a history of LVAD infection and required daily sterile wet kit dressing changes to prevent further infection. Upon arrival at the facility, the resident's dressing had not been changed for 11 days, and the correct supplies were not readily available. Additionally, staff used an automatic blood pressure machine, which is not appropriate for LVAD patients, instead of the required manual method. These failures were confirmed through record review, staff interviews, and direct observation, indicating that the facility did not follow the physician's orders or the resident's care plan for LVAD management.