F0684

G

Failure to Respond Timely to Resident’s Repeated ICD Shock Complaints

Dayton, Ohio Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely, adequate, and necessary care, monitoring, and treatment following an acute change in condition for a resident with an implanted cardioverter defibrillator (ICD). The resident, who had a history of stroke, COPD, acute respiratory failure with hypoxia, coronary artery disease from ischemic cardiomyopathy, a low ejection fraction, prior coronary artery bypass grafting, and ICD placement, was alert and oriented per a recent MDS. On the day in question, the resident repeatedly complained of being shocked and screamed out in pain throughout the day. One LPN reported that the resident stated a man or the bed was shocking him; she suspected a UTI, unplugged and checked the bed, took vital signs, and wrote a note in a provider binder for follow-up the next day, but did not document the event in the medical record or notify a physician. She also stated she did not know the resident had an ICD.

Later that evening, an RN received report that the resident had been screaming all day about being shocked. When the RN assessed the resident around 9:30 P.M., the resident reported being shocked by his pacemaker. The RN, who stated he was unaware of the pacemaker until the resident mentioned it, reviewed the record and confirmed the device, noted an irregular and elevated heart rhythm, and documented that the resident complained of a shocking feeling in his chest with heart rates of 64 and 69 bpm. The RN attempted to contact the on-call provider but received no answer and awaited a return call; he did not obtain further orders or send the resident to the hospital before the end of his shift. He reported to the oncoming LPN that the resident had complained of being shocked and instructed that the resident should be sent out if it occurred again.

About an hour into the night shift, the oncoming LPN heard the resident screaming in pain, assessed him, and documented that the resident complained of ICD shocks that had been occurring for the last four hours. At that time, the resident’s vital signs included a BP of 94/59 mmHg, HR 92, RR 22, and O2 saturation of 96%, and the resident requested to go to the emergency room because the shocks were scaring him. The LPN contacted the on-call provider, who agreed to send the resident to the hospital, and EMS was called. EMS documented that the resident reported 12–15 ICD shocks in the prior three hours, with heart rates rising to 225 bpm and atrial fibrillation with rapid ventricular response. Hospital records and the medical director’s note later indicated the resident had been in ventricular tachycardia with repeated ICD defibrillations, hypokalemia, and more than 35 shocks per ICD report, requiring antiarrhythmic medications, IV drips, and ICU admission. The facility’s change in condition policy required vigilant monitoring, comprehensive assessment, documentation in the medical record, and immediate physician notification for significant changes, which were not consistently followed in this case.