Failure to Obtain Physician Order and Care Plan for Cardiac Life Vest
Penalty
Summary
The facility failed to obtain a physician order, develop a care plan, and monitor the use of a cardiac life vest for one resident with a history of congestive heart failure and chronic obstructive pulmonary disease. Upon admission, the resident was wearing a cardiac life vest, but staff did not address its use in the admission assessment or care plan. Nursing progress notes mentioned the presence of the life vest, but there was no documentation in the physician progress notes or the physician order sheet regarding its use, application, battery changes, cleaning, or monitoring requirements. Interviews with various staff members, including LPNs, CNAs, the MDS Coordinator, the ADON, and the DON, revealed a lack of awareness, training, and experience regarding the care and monitoring of cardiac life vests. Staff consistently stated that a physician order and care plan should have been in place for the life vest, including instructions for skin assessments, battery changes, and monitoring. However, none of these actions were documented or implemented for the resident in question. The deficiency was further evidenced by the absence of any mention of the cardiac life vest in the care plan and the lack of staff education on its use. The resident's use of the device was only discovered after admission, and staff relied on the resident to manage aspects of the device, such as battery changes. The facility's policies required individualized care planning and current physician orders for all treatments and devices, but these were not followed in this case.