Failure to Administer Diuretic Medication Leads to Hospitalization
Penalty
Summary
The facility failed to provide care in accordance with physician orders and professional standards for Resident #49, who was admitted with diagnoses including congestive heart failure (CHF) and a pacemaker. Upon admission, the resident's diuretic medication, Lasix, was not administered as ordered, leading to significant weight gain and worsening of his medical condition. Despite the resident's attempts to communicate the need for Lasix to the nursing staff, the medication was not consistently provided, resulting in hospitalization for fluid overload and management of skin breakdowns. The Clinical Nurse Supervisor (CNS) confirmed that the resident's diuretic was listed on hospital paperwork but was not administered regularly. The resident's weight was monitored daily due to CHF, but significant weight increases were not reported to the physician, nor were there any adjustments made to the diuretic medication. The resident's weight increased from 94.2 kg at admission to 106 kg by the time of re-hospitalization, with no documentation of provider notification or intervention. Interviews with the Nurse Practitioner (NP) and review of medical records revealed that the facility's Medical Doctor (MD) had noted the need for continued Lasix, but the medication was not consistently administered. The resident's cardiologist identified the lack of Lasix administration during a pacemaker check, leading to the resident's admission to the hospital for diuresis. The facility's failure to administer Lasix as ordered and to address significant weight changes contributed to the resident's deteriorating condition and subsequent hospitalization.
Plan Of Correction
F684 Element #1: Resident #49 physician orders and treatment reviewed and appropriate. Element #2: Residents that reside in the facility have the potential to be affected. Residents have been reviewed for significant change in condition with physician notification. Element #3: Licensed Nurses have been educated on the facility's Change in Condition Notification of Clinician policy. Element #4: Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Director of Nursing or designee(s) will conduct weekly audits for residents who have significant change in condition physician communication. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element #5: The Administrator is responsible for sustained compliance.