Failure to Update and Revise Care Plans for Assistive Devices and Pacemaker Precautions
Penalty
Summary
The facility failed to review and revise the care plans for two residents as required by both facility policy and regulatory standards. For one resident with dementia, hypertension, and atrial fibrillation, the clinical record showed the use of bilateral enabler bars and a pacemaker monitoring unit, but the care plan did not include interventions or safety precautions related to the enabler bars or the pacemaker. Documentation confirmed the enabler bars were ordered and placed, and the resident had a pacemaker since 2018, yet these were never addressed in the care plan or its revision history. The Nursing Home Administrator and Director of Nursing confirmed that these items should have been included in the care plan. Another resident with morbid obesity and lumbar spondylolisthesis used bilateral enabler bars and a trapeze for bed mobility and transfers, with staff performing safety checks as ordered by the physician. Although there was a signed consent and risk-benefit form for the use of bed rails, the care plan and Kardex did not document the use of the enabler bars or trapeze. The Nursing Home Administrator confirmed via email that these devices were not documented in the care plan or Kardex, despite their use and the associated physician orders.