Failure to Develop Baseline Care Plan for Resident with LVAD
Penalty
Summary
The facility failed to develop and implement an individualized baseline care plan for a resident with a left ventricular assist device (LVAD) within 48 hours of admission, as required by facility policy. Upon admission, the resident had a documented history of chronic systolic congestive heart failure, atrial fibrillation, and an LVAD. Despite these significant medical needs, the baseline care plan and physician orders did not include specific interventions or monitoring parameters for the LVAD, such as checking VAD parameters every shift, performing controller and power module self-tests, or monitoring alarms and batteries. Interviews and record reviews revealed that the initial stabilization visit and subsequent documentation focused on general medication review and stabilization, but did not address the LVAD care requirements. The admission evaluation acknowledged the presence of the LVAD, but failed to include goals or interventions specific to the device. Staff interviews indicated a lack of clarity regarding the necessary baseline care needs and orders for residents with an LVAD, and the comprehensive care plan was only revised to include LVAD care after the surveyor's inquiry, not as part of the initial baseline plan. Facility policies required that baseline care plans be person-centered and based on admission orders, including all necessary instructions for effective care. However, the facility did not ensure that orders and interventions for LVAD care were in place upon admission, and staff were unable to specify what those orders should be. The LVAD policy, which outlined required monitoring and care procedures, was not presented to the surveyor until later in the survey, and was not referenced or implemented in the resident's initial care planning.