| 97 |
PROVIDENCE TRANSITIONAL CARE CENTER |
25018 |
910 COMPASSION CIRCLE |
ANCHORAGE |
AK |
99504 |
2018-07-13 |
684 |
E |
0 |
1 |
FK4811 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure 3 residents (#'s 16, 24 and 39), out of 3 residents reviewed with cardiac devices (devices implanted under the skin with wires attached to the heart to ensure a regular heartbeat) had the required monitoring of the device. This failed practice placed the residents at risk for undiagnosed heart rhythm irregularities, missed device changes or alerts, and decreased heart health. Findings: Resident #16 Record review from 7/9-13/18 revealed Resident #16 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of Resident #16's care plan, last updated 5/9/17, revealed no documentation of the presence of a pacemaker or any type of cardiac device monitoring. Review of Resident #16's Resident Daily Care Plan (RDCP), dated 5/15/18, revealed no documentation of a cardiac pacemaker. Record review of Providence Alaska Medical Center's Admission History and Physical, dated 4/11/18, revealed Review of old records indicate that patient is had a pacemaker placed for heart block following a [MEDICAL CONDITION] infarction. This was in 2008. Record review of PTCC (Providence Transitional Care Center) ADMISSION TRANSFER REPORT, dated 4/26/18, revealed PMH (past medical history): .PACEMAKER. Review of PHYSICIAN ORDER REVIEW, dated 5/3/18, 5/27/18 and 6/28/18 revealed INFO: Patient has PACEMAKER . Observations of the resident's room from 7/9-13/18 revealed no telephonic equipment, used for cardiac pacemaker monitoring, present for the Resident. An interview on 7/12/18 at 3:10 pm, with Alaska Heart & Vascular Institute Electrophysiology Clinic Manager (AH&VI EP Manager), revealed Resident #16 had his/her last pacemaker transmittal on 1/24/18. The Resident was scheduled for transmittals 5/1/18, 5/15/18, 6/5/18, and 6/19/18. The Manager stated as these transmittals were all missed, no other transmittals had been scheduled for this Resident. Resident #24 Record review from 7/9-13/18 revealed Resident #24 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #24's care plan, last updated 6/6/18, revealed no documentation of the presence of a cardiac pacemaker or pacemaker device monitoring. Review of Resident #24's Resident Daily Care Plan, dated 6/28/18, revealed no documentation of a cardiac pacemaker. Random observations of the resident's room from 7/9-13/18 revealed no telephonic equipment, used for cardiac pacemaker monitoring, present for the Resident. During an interview on 7/12/18 at 10:10 am, with Resident #24's son, the son stated he had no interaction with the staff regarding Resident #24's pacemaker. During an interview on 7/12/18 at 3:10 pm, with AH&VI EP Manager stated Resident #24's last pacemaker check was on 11/14/17. The next scheduled pacemaker check was for 2/16/18, this check was canceled by Resident #24's son. The Manager stated device checks are recommended every three months and no other device checks were scheduled for Resident #24. Resident #39 Record review from 7/9-13/18 revealed Resident #39 was admitted to the facility with [DIAGNOSES REDACTED]. Interview on 7/9/18 at 9:17 am, Resident #39 stated that they had a BI-V ICD for several years. Record review of the Nursing Facility Needs assessment dated [DATE] revealed under Cardiac, documentation Resident #39 had a pacemaker/ICD. Record review of Resident #39's care plan, last updated 6/13/18, revealed no documentation of a plan to monitor Resident's pacemaker/ICD. Review of Resident #39's Resident Daily Care Plan, dated 6/1/18, revealed no documentation of a cardiac pacemaker/ICD. Random observations of the Resident's room from 7/9-13/18 revealed no telephonic equipment, used for cardiac pacemaker/ICD monitoring, present for the Resident. During an interview on 7/11/18 at 2:35 pm, Licensed Nurses #1 and #2 stated they did not know of telemetry boxes or need of monitoring equipment for pacemakers. During an interview with the Alaska Heart & Vascular Institute Electrophysiology Clinic Manager (AH&VI EP Manager), when asked how often cardiac devices are monitored, he/she stated that telephonic transmittals should be done every 3 months. During an interview on 7/12/18 at 4:03 pm, the Director of Nursing (DON) stated the Nurse Educator assesses where the resident is being seen for his/her pacemaker care. The DON also stated if residents have a device at home to check the pacemaker they bring the device so it can be done at the facility. The family or resident tells staff they have a pacemaker check coming up and the residents are sent out for the check. In addition, the DON stated she is not sure what happens after the pacemaker is put on the [DIAGNOSES REDACTED]. Review of the facility policy index from 7/10-13/18 revealed no policy on pacemakers or ICD's. During an interview on 7/11/18 at 4:02 pm the DON stated the facility did not have a policy. The facility provided the survey team a list of their policies during the survey. The Surveyors requested a policy on pacemakers and defibrilators which the Surveyors hand wrote on the list. When the policies requested and the list given were given to the Surveyors a hand written protocol was by the cardiac device request. A protocol was then requested. The protocol was not provided by the survey exit. |
2020-09-01 |