Failure to Provide Adequate Care for Resident with Heart Failure
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of eight out of fifteen residents, as confirmed by the Nursing Home Administrator and the Director of Nursing. Additionally, the facility did not provide adequate care and services to prevent hospitalization and failed to provide necessary care after hospitalization for one resident. This resident, who had a history of chronic obstructive pulmonary disease (COPD), diabetes, and heart failure, was admitted to the facility and later readmitted after a hospital stay. The resident experienced significant weight fluctuations and was transferred to the hospital due to abdominal pain, confusion, and increased blood pressure and heart rate, leading to a diagnosis of exacerbation of congestive heart failure (CHF). Upon returning to the facility, the resident's physician's orders did not include monitoring for signs and symptoms of CHF exacerbation, such as fluid status, weight gain, swelling, or shortness of breath. Furthermore, the resident's care plan was not updated to address heart failure, and the physician's progress notes lacked information related to heart failure. These deficiencies were confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to provide necessary care and services to potentially prevent hospitalization and to adequately care for the resident post-hospitalization.
Plan Of Correction
1. R22's medical records and care plan have been reviewed and updated. 2. (and "like" residents), focusing on the management of congestive heart failure (CHF) have been reviewed and updated. 3. The Director of Nursing/Designee will provide retraining for all nursing staff on the standards of care for managing residents with CHF, including the importance of monitoring symptoms, weight management, and fluid balance. 4. The Director of Nursing/Designee will include training on recognizing signs of exacerbation of CHF and the appropriate steps to take when changes in a resident's condition are observed. 5. The Director of Nursing/Designee will conduct weekly audits times two, then monthly for two months to ensure that care plans are being followed for residents with high-risk conditions like CHF. 6. The Director of Nursing/Designee will use audit results to identify areas for improvement and adjust care practices accordingly. 7. Audit results will be reviewed during monthly Quality Assurance Performance Improvement meetings, and findings will be documented.