Failure to Document Pacemaker Information in Resident Record
Penalty
Summary
The facility failed to ensure that a resident with a cardiac pacemaker had the device's make, model, and related information documented in the medical record. Record reviews showed that the resident's admission record did not include a diagnosis description for a cardiac pacemaker, and the care plan lacked the required pacemaker information. The resident's MDS assessment indicated the presence of a pacemaker and moderate cognitive impairment, and the care plan referenced the need for monitoring and documentation of pacemaker-related symptoms, but the specific device details were missing. Additionally, there were no physician orders related to the pacemaker in the resident's consolidated orders. Interviews with staff confirmed awareness of the resident's pacemaker, but the Director of Nursing (DON) acknowledged that the make and model were only available in an email and had not been entered into the resident's record. The corporate administrator stated there was no pacemaker policy, and the care plan preparer indicated that the make and model were added to the care plan only after the surveyor's inquiry. The DON also confirmed the absence of a physician's order for the pacemaker and stated that such devices should have an order for proper monitoring.