Failure to Monitor CHF Residents and Administer PRN Diuretics as Ordered
Penalty
Summary
The facility failed to ensure adequate disease management and monitoring for two residents with congestive heart failure (CHF). For one resident, staff did not consistently monitor daily weights as ordered, nor did they notify the physician of significant weight fluctuations, including gains of over 3 pounds in 24 hours and over 7 pounds in one day. The resident's electronic medical record lacked documentation of physician notification for these weight changes, and there were missed daily weights. The resident experienced increased edema, decreased oxygen saturation, and eventually required emergency transport to the hospital after reporting chest pain and shortness of breath. Additionally, the facility did not administer as-needed (PRN) Lasix for another resident with CHF, despite a physician's order to do so for weight gains exceeding specified parameters. Staff failed to weigh this resident daily as ordered, instead switching to monthly weights, and did not administer the PRN diuretic even after a significant weight gain of over 18 pounds. The care plan for this resident also lacked instructions regarding the use of PRN Lasix. Interviews with nursing staff revealed a lack of awareness of the PRN Lasix order and improper handling of weight documentation, including one nurse striking out weights recorded by others. Administrative staff confirmed that the facility's standing orders and policies were not followed, as staff did not consistently monitor weights or notify providers according to established parameters for residents with CHF.