Incomplete Care Plan for Resident with Cardiac Pacemaker
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a cardiac pacemaker. Record reviews showed that the care plan did not include essential information such as the pacemaker's name, serial number, or instructions on device care. Additionally, there was no documentation of a recent cardiac physician appointment to check the status of the pacemaker, and the Medication Administration Record (MAR) did not address pacemaker care. The care plan only mentioned avoiding electromagnetic interference and did not specify signs and symptoms to report to the physician immediately. There was also no evidence of a scheduled cardiac physician appointment in the resident's chart. During interviews, both the resident and a registered nurse confirmed the presence of a cardiac pacemaker, but administrative staff were unable to provide information regarding the device's details or recent follow-up care. The facility's policy requires comprehensive care plans to include measurable objectives and timeframes to meet residents' medical, nursing, and psychosocial needs, but this was not followed in the case of the resident with a pacemaker.