F0684

E

Failure to Follow LVAD-Related Physician Orders and Monitoring Requirements

Pottstown, Pennsylvania Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement multiple physician orders for a resident with congestive heart failure, a left ventricular assist device (LVAD), and atherosclerosis of coronary artery bypass grafts. Clinical record review for a specified period in January 2026 showed missing documentation that staff performed required LVAD self-tests every shift on two occasions. Staff also did not document required LVAD parameters (pump rate, pulse index, pump power, pump speed) and vital signs on six occasions, and there was no documented evidence that staff used a doppler to obtain mean blood pressure twice daily as ordered. In addition, staff failed to document that they ensured backup LVAD batteries were on charge and verified every shift on two occasions.

Further review showed that staff did not document obtaining daily weights on four occasions, despite orders to monitor weights and notify the provider of significant changes. There was no documented evidence that staff converted the LVAD to battery power once daily and returned it to main power at bedtime on two occasions. Staff also failed to document observing for signs and symptoms of driveline infection every shift on three occasions. When the resident was transferred to the hospital for a change in condition, there was no documented evidence that the resident was sent with the ordered backup controller, two extra batteries, and two extra clips. In an interview, the DON confirmed there was no evidence that staff implemented these physician orders as required.