Failure to Develop and Implement Comprehensive Care Plans for Residents with Medical Devices
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents with specific medical devices and needs. For one resident with chronic kidney disease, anemia, and hypertension, the care plan inaccurately addressed a shunt for dialysis access, when the resident actually had a right upper chest tunneled central venous catheter. The care plan included interventions appropriate for a shunt, such as avoiding blood pressure measurements or blood draws in the shunt extremity and instructing the resident not to sleep on the side with the shunt, none of which were applicable. This inaccuracy was confirmed by both nursing staff and the MDS nurse, who acknowledged that the care plan did not reflect the correct dialysis access or the appropriate interventions required for a central venous catheter. Another resident, admitted with diagnoses including subdural hemorrhage, end stage renal disease, atherosclerotic heart disease, and atrial fibrillation, had a Zio Patch heart monitor placed by a cardiologist. Upon returning to the facility, the resident reported the presence of the device to nursing staff but did not receive any explanation or care instructions. The care plan was not updated to address the presence of the Zio Patch, and there were no interventions documented for monitoring the device, assessing skin integrity, or ensuring the device was returned as required. The MDS nurse and DON both confirmed that the care plan did not include the necessary information or interventions for the heart monitor. The facility's policy requires that comprehensive, person-centered care plans with measurable objectives and timetables be developed and implemented for each resident, and that care plans be revised as residents' conditions change. In both cases, the facility did not follow this policy, resulting in care plans that did not address the residents' actual needs or the specific care required for their medical devices.