Failure to Monitor and Assess VP Shunt According to Standards
Penalty
Summary
The facility failed to ensure that a resident with a ventriculoperitoneal (VP) shunt received treatment and care in accordance with professional standards of practice. The resident, who had congenital hydrocephalus and a cerebrospinal fluid drainage device, was severely cognitively impaired and required regular monitoring of the VP shunt for complications such as infection or malfunction. The care plan directed nursing staff to pump the shunt as per neurosurgeon instructions but did not include interventions for assessment of the shunt line for infection or abdominal assessment for signs of fluid overload related to cerebrospinal fluid drainage. Review of the resident's records showed that while the shunt was pumped as ordered, there was no documentation of the number of pumps performed, nor were there any documented assessments of the abdomen or the shunt for signs of infection or other complications. Interviews with nursing staff revealed that their training was limited to the mechanical aspect of pumping the shunt, with no education or documentation regarding assessment for potential complications. The Director of Nursing was unable to provide evidence of staff training or assessment protocols related to the VP shunt, and no additional physician orders for assessment were present.