Failure to Address Pacemaker Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan that addressed the monitoring and care of a resident's pacemaker. Despite the resident having a documented medical history of atrial fibrillation, heart failure, and severe cognitive impairment, the care plan did not include any focus area or interventions related to the presence or management of a pacemaker. The resident's admission records and Minimum Data Set assessment confirmed these diagnoses and cognitive status, and the care plan only addressed risks for cardiac complications without specifying the pacemaker. Further review of the resident's order summary revealed an order indicating the presence of a pacemaker, with instructions for staff to be aware of this every shift. However, there were no corresponding interventions or guidance in the care plan for staff on how to monitor the pacemaker for proper functioning. Interviews with the resident and the Director of Nursing confirmed the existence of the pacemaker and the expectation that it should be addressed in the care plan, but this was not done.