Failure to Monitor Pacemaker and Inadequate Response to Resident Fall
Penalty
Summary
Licensed nursing staff failed to obtain and follow orders for monitoring a resident's pacemaker for proper functioning. The resident, who had a history of cardiomyopathy, heart assist device, and congestive heart failure, was admitted with a pacemaker, but the care plan did not include interventions for pacemaker monitoring. The only order present was an informational note about the presence of a pacemaker, with no directive for staff to monitor its function. Interviews confirmed that the resident could not recall the last time their pacemaker was checked, and facility leadership acknowledged that no monitoring was being performed by staff. In a separate incident, staff failed to follow facility policy regarding the management of resident falls. A resident with muscle weakness, difficulty walking, and moderate cognitive impairment fell out of bed. The assigned Geriatric Nursing Assistant (GNA) enlisted the help of a housekeeper to lift the resident back into bed without notifying a licensed nurse or having the resident assessed prior to being moved, as required by policy. The fall was not reported to nursing staff until the following day, after the resident complained of leg pain. Both deficiencies were identified through interviews, record reviews, and policy review, which revealed that staff did not follow established protocols for monitoring medical devices and responding to resident falls. The lack of appropriate orders and failure to report and assess a fall before moving the resident directly contributed to the deficiencies cited.