Missing Pacemaker Documentation in Resident Record
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that a resident admitted with a pacemaker had complete and necessary information about the device documented in the clinical record. Upon review, the resident's admission record and physician order confirmed the presence of a pacemaker, but the clinical record lacked essential details such as the cardiologist's information, implant date, device model and serial number, lead model and serial number, battery longevity, device settings, and scheduled checkup period. During an interview, the DON was unable to locate any pacemaker information in the resident's record, despite facility policy requiring all pacemaker documentation to be included in the resident's chart and permanent record.