Failure to Develop Comprehensive Care Plan for Pacemaker Management
Penalty
Summary
The facility failed to develop a comprehensive, individualized care plan for a resident with a pacemaker. The care plan in place identified the presence of a pacemaker and associated risks, such as activity intolerance, pacemaker failure, and altered cardiac output, and included an intervention to monitor vital signs and notify the physician of significant abnormalities. However, the care plan lacked specific details and individualized interventions related to the monitoring and care of the pacemaker. Record review showed that the resident's physician orders did not include essential information such as the pacemaker setting rate, serial number, or cardiologist contact details. Interviews with nursing staff and the Director of Nursing confirmed that this information should have been present in the physician orders to guide care. The absence of these details meant that staff did not have the necessary information to properly monitor and respond to the resident's cardiac needs.