F0657

D

Failure to Update Care Plan for Pacemaker Monitoring System

Pomona, California Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The facility failed to revise and update the care plan for a resident with a cardiac pacemaker after a pacemaker monitoring system was introduced, as required by facility policy. The resident was admitted with diagnoses including heart failure, hypertension, and the presence of a cardiac pacemaker. The existing care plan, initiated on 8/26/2025, addressed altered cardiovascular status related to pacemaker placement and included monitoring, documenting, and reporting chest pain or pressure. The resident’s H&P and MDS documented that the resident was cognitively intact, able to make decisions, and able to understand and be understood, with some need for assistance in activities of daily living.

On 11/25/2025, progress notes documented that a family member brought in a heart monitor for the resident and instructed staff to plug it in and place it close to the resident. Despite this new intervention, there was no corresponding update to the resident’s care plan to include the use of the pacemaker monitoring system. During interviews, the ADON and RN acknowledged that the care plan had not been updated to reflect the pacemaker monitoring system and stated it should have been revised because it was important information regarding the resident’s heart. The DON also stated that care plans should be updated because they serve as a guide for staff to ensure appropriate interventions are in place. Review of the facility’s “Pacemaker - Management” policy indicated that pacemaker care was to be incorporated into the resident’s care plan, including specific interventions, monitoring frequency, and safety precautions, and the “Completion & Correction” policy required complete and accurate medical records with prompt, descriptive, and accurate entries.