Failure to Include Cardiac Loop Monitor in Resident Care Plan
Penalty
Summary
The facility failed to fully develop and implement a care plan addressing all of a resident's needs, specifically omitting the presence and management of an implanted loop cardiac monitor for one resident. Documentation showed that the resident had a loop monitor inserted, with supporting medical records and physician orders indicating the need for the device to be plugged in and functioning at the bedside every shift. Despite this, the resident's care plan did not reflect the presence of the loop monitor until after a hospital stay, even though the device had been implanted and in use prior to that time. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's medical device. A certified nurse aide was unaware of the device, and an LPN stated that there was no order for the loop monitor prior to the recent hospital stay, with knowledge of the device being passed only through verbal report. The MDS coordinator confirmed that the loop monitor was not included in the care plan until after the hospital stay, and noted that staff would not have known about the device outside of direct observation or communication with the resident's family.