F0684

D

Failure to Obtain Orders and Document Pacemaker Monitoring Device Use

Pomona, California Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain physician orders and instructions for a newly implemented pacemaker monitoring device (PMD) and to ensure the resident’s cardiac pacemaker information was readily accessible in the medical record as required by facility policy. A resident with diagnoses including heart failure, hypertension, and the presence of a cardiac pacemaker was cognitively intact and able to make decisions. After returning from a cardiology appointment, the resident’s family member brought a heart monitor (PMD) to the facility and instructed a registered nurse to plug it in and place it near the resident for monitoring by the cardiologist. The nurse followed the family member’s instructions but did not contact the resident’s physician or cardiologist to obtain an order for the PMD or to receive instructions on its use.

Interviews and record review confirmed there were no orders or instructions in the resident’s paper or electronic chart regarding the PMD, despite facility policy titled “Pacemaker – Management” requiring standardized guidelines for safe and effective care of residents with pacemakers. The DON stated that the nurse should have obtained orders and validated instructions such as acceptable distance for transmission, duration of use, charging procedures, and response to alarms. Additionally, review of the resident’s care plan for altered cardiovascular status related to pacemaker placement showed monitoring for chest pain or pressure, but there was no documentation that the PMD use and related pacemaker information were incorporated into the resident’s accessible medical record as indicated in the facility’s pacemaker management policy and lesson plan for licensed nurses.