Failure to Develop Comprehensive Care Plans for Residents with Pacemaker and Tracheostomy
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for two residents with specialized medical needs. For one resident with a cardiac pacemaker and a diagnosis of sick sinus syndrome, clinical and hospital records documented the presence of the pacemaker, but the resident's care plan did not address the device, associated checks, assessments, or necessary precautions. This omission was confirmed through review of the care plan and discussion with facility leadership. For another resident with a tracheostomy, the care plan included some interventions such as securing trach ties, elevating the head of the bed, providing oral care, and suctioning as needed. However, the care plan did not address potential complications like unplanned extubation or airway emergencies, nor did it include the requirement for an emergency tracheostomy tube at the bedside as specified in facility policy. Observations confirmed the presence of a tracheostomy, and staff interviews indicated the lack of an emergency kit at the bedside, further evidencing the incomplete care planning.