Failure to Update Care Plan for Resident with New Heart Monitor
Penalty
Summary
The facility failed to review and revise the care plan for a resident who returned from a cardiology appointment with a new external heart monitor. The resident was observed with the device in her room, and she reported that the monitor was placed during her recent follow-up appointment to evaluate for possible atrial fibrillation. Upon returning to the facility, she provided the related paperwork to a staff member. However, for approximately 48 hours, the facility staff, including the Director of Nursing, were unaware of the presence of the heart monitor and did not implement monitoring or update the resident's care plan to reflect this new device. Record reviews, including shower and skin monitoring sheets and progress notes for the relevant dates, showed no documentation acknowledging the heart monitor. Interviews with staff confirmed that the process for verifying and documenting new physician orders was not followed in this instance. The care plan was not updated to address the resident's new needs related to the heart monitor, as confirmed by both documentation review and photographic evidence.