Failure to Provide Comprehensive Care Plan for Cardiac Pacemaker
Penalty
Summary
The facility failed to ensure that a resident with a cardiac pacemaker received treatment and care in accordance with professional standards of practice and the resident’s comprehensive person-centered care plan. Record reviews showed that the resident’s diagnosis of a cardiac pacemaker was documented, but there was no physician order specifying the pacemaker’s serial number or instructions for device care. The Medication Administration Record (MAR) for the resident did not include care for the cardiac pacemaker, and the care plan lacked essential details such as the device’s name, serial number, and information about recent cardiac physician appointments to check the pacemaker’s status. The care plan only included instructions to report signs and symptoms to the physician immediately. Observations confirmed the presence of a cardiac pacemaker, and both the resident and nursing staff acknowledged its existence. However, during interviews, the Administrator and Director of Nursing were unable to provide information regarding a recent cardiac appointment or a policy specific to pacemaker care. The facility’s policy on comprehensive care plans requires that all services identified in the resident’s assessment be included to meet professional standards, but this was not followed for the resident with the pacemaker.