Failure to Develop Comprehensive Pacemaker Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents with cardiac pacemakers. For one resident with chronic obstructive pulmonary disease and a pacemaker, the care plan did not include essential pacemaker information such as the make, model, serial number, implant date, paced rate, frequency of pacemaker checks, or cardiologist contact details. The resident was dependent on staff for daily activities and had an active diagnosis of a cardiac pacemaker, but the care plan lacked the required documentation and monitoring details as outlined in the facility's own policy. Similarly, another resident with an atrioventricular block and a pacemaker did not have a care plan that included the cardiologist's information, paced rate, or frequency of pacemaker checks. Interviews with nursing staff revealed uncertainty about the need to include specific pacemaker information in care plans, and the DON confirmed that such details should be present. The facility's failure to document and plan for the monitoring and care of residents with pacemakers was identified through record review and staff interviews.