Failure to Assess and Monitor Cardiac Device Use
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care and treatment for a resident who required cardiac monitoring. The resident, who had a history of hemiplegia, hemiparesis following a stroke, congestive heart failure, COPD, emphysema, and atrial fibrillation, was admitted with moderate cognitive impairment and was responsible for their own healthcare decisions. After a cardiology appointment, the resident returned to the facility with a cardiac monitor in place, but there was no documentation of new orders or instructions regarding the monitor. Staff did not assess the resident's ability to follow cardiac monitoring instructions, nor did they document any monitoring assessments, device checks, or symptom reporting related to the cardiac monitor. Interviews with staff revealed that the folder sent with the resident to the appointment was empty upon return, and no follow-up was conducted to obtain necessary paperwork or orders from the clinic. The LPN acknowledged that there was no documentation regarding the duration of monitor use, frequency of assessments, or device checks. The respiratory therapist who applied the monitor noted that the resident was unable to clearly express understanding of how to use the device. The DON confirmed that there was no documentation of follow-up or monitoring related to the cardiac monitor in the resident's medical record, and that such assessment and monitoring should have been included in the plan of care.