Failure to Follow Professional Standards for LVAD Care and Monitoring
Penalty
Summary
The facility failed to follow professional standards of care for residents with Left Ventricular Assist Devices (LVADs), affecting two residents. For one resident, the facility did not adequately assess or monitor the LVAD battery levels, nor did staff intervene when the batteries became depleted. This resident had a complex medical history including heart failure, diabetes, and cognitive deficits, and required regular LVAD checks. Despite policy requiring battery changes at 50% capacity, staff did not consistently check or change the batteries, and the LVAD was found to be without power, resulting in a cardiac arrest event. Documentation and interviews revealed that multiple staff members on duty did not perform required LVAD system checks, did not change or charge the batteries, and some staff lacked training or competency in LVAD care. Video surveillance confirmed that staff did not enter the resident's room to perform necessary assessments during critical periods. Additionally, the resident's care plan and physician orders did not include comprehensive instructions or interventions for LVAD management, particularly for night shifts. The baseline and comprehensive care plans lacked goals and interventions specific to the LVAD, and there were no orders for monitoring or managing the device overnight. Staff interviews indicated confusion about responsibilities and a lack of hands-on training, with some staff unaware of how to check battery levels or perform system checks. The facility's own policies required regular monitoring and battery changes, but these were not followed, and the LVAD policy was not readily available when requested by surveyors. For the second resident with an LVAD, the facility failed to ensure that physician orders were in place for LVAD management upon admission. The initial stabilization visit and baseline care plan did not address the LVAD, and there were no orders for monitoring alarms, system checks, or battery status. The comprehensive care plan was only updated after surveyor inquiry, and staff could not specify the baseline care needs for a resident with an LVAD. The facility's policies required the development of a person-centered care plan within 48 hours of admission, but this was not done for the resident with the LVAD.