Failure to Notify CHF Clinic of Significant Weight Gain in Resident
Summary
The facility failed to ensure that a resident with a diagnosis of congestive heart failure (CHF) received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not notify the CHF clinic of the resident's significant weight gain as required by provider orders. The resident experienced a weight increase of more than 10 pounds within a week, as documented in daily weight records, and exhibited symptoms such as shortness of breath and low oxygen saturation levels. Despite clear physician orders to notify the CHF clinic for weight gains of 2 or more pounds overnight or 3-5 pounds in one week, there was no documentation in the nursing progress notes that such notifications were made during the period of weight gain. Interviews with nursing staff confirmed that although weights were taken and abnormal findings were reported during shift handovers, no direct notification was made to the CHF clinic. The resident's care plan also included interventions to monitor for respiratory distress and to contact the medical provider if noted, but these interventions were not fully implemented as required. The lack of timely notification resulted in the resident requiring IV Lasix administration at the CHF clinic after the significant weight gain and onset of shortness of breath. Family members and clinical staff from the CHF clinic confirmed that they were not informed of the resident's weight changes by the facility, which led to a delay in care. The facility's own policy required prompt notification and documentation of changes in condition, but this was not followed in this case, as confirmed by interviews with the DON, nursing staff, and the resident's physician.
Removal Plan
- The facility activity report and the 24-hour report will be audited by the Director of Nursing/Designee to identify any documentation that indicates changes in resident's condition and notification to provider as ordered.
- The Director of Nursing will be reeducated by the Clinical Consultant on following providers orders to prevent a delay in treatment and change in condition including: prompt notifications documented in residents medical record to providers as designated in provider orders; all attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record; notifications to required medical staff of weight changes as ordered; nursing leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor; shortness of breath; weight gain in residents with Congestive Heart Failure causing shortness of breath.
- Licensed nurses, including PRN nurses, will be reeducated by the Director of Nursing/Designee on following provider orders to prevent a delay in treatment and change in condition including: prompt notifications to providers as designated in provider orders; all attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record; notifications to required medical staff of weight changes as ordered; shortness of breath; weight gain in Congestive Heart Failure residents causing shortness of breath. Licensed Nurses, including PRN nurses not receiving this education will receive prior to their next scheduled shift and this will be completed in New Hire orientation.
- Director of Nursing/Designee will review the Facility Activity Report and 24-hour report in clinical morning meeting to identify any documentation regarding a change in condition and validate the resident has been assessed appropriately and provider notified. The Weekend Supervisor will validate on the weekend. This will continue for 4 weeks, then randomly for 2 additional months.
- The Administrator will oversee the continuation of this plan.
- Ad Hoc QAPI will be held.
- The Medical Director was notified of the Immediate Jeopardy and contents of this plan.
- Monitoring included the following: Record review completed of the facility 24-hour report. Completed by the DON. All residents in the facility were reviewed for any concerns identified and marked for follow up.
- Record review of an in-service titled: Change of Condition monitoring, reviewing clinical documentation and signs & symptoms of CHF exacerbation with proper notification to providers of changes.
- Record review of an additional in-service on prompt notifications to providers, documentation, and validation in clinical morning meetings.
- Record review of in-service titled Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms.
- Record review of a staff in-service revealed staff were educated on Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms.
- Record review of a staff in-service revealed staff were educated on prompt notifications to providers, documentation, notifications to required medical staff of weight changes as ordered, shortness of breath, and weight gain in Congestive Heart Failure residents causing shortness of breath.
- Record Review of training titled: Change of Condition revealed staff were trained on licensed nurses must notify providers of change of condition for orders if necessary to prevent a delay in treatment including: prompt notifications to providers as designated in provider orders; all attempts to notify medical staff and responsible parties will be documented in resident's medical record; notifications to required medical staff of weight changes as ordered.
- Record review of the Adhoc QAPI for F684 revealed the meeting included the ADM, DON, CC, and MD.
- Record Review of a signed statement by the DON revealed notification to the MD regarding Immediate Jeopardy.
- Record review of the new hire orientation packet which included an added section revealed the following: respiratory care all nurses validate resident is receiving oxygen per MD orders; change of condition recognition and notification to providers; prompt notification to providers, all attempts to notify medical staff and RP will be documented in residents medical record; notifications to require medical staff of weight changes as ordered. SOB, weight gain in CHF resident causing SOB; policy on physician and other communication /change in condition policy added and packet on the Management of heart failure preventing and managing exacerbations & comorbidities.
- Record review of education provided to the only 2 agency nurse staff working revealed education included change of condition and CHF education.
- Record review of an email from the DON to RN C revealed communication with RN C on change of conditions and early warning signs of CHF exacerbation and the need to notify.
- Record review of an email from the DON to LVN B revealed communication with LVN B on change of conditions and early warning signs of CHF exacerbation and the need to notify/ Management of Heart Failure.
- Record review of text messages from the DON to LVN A revealed LVN A was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify.
- Record review of text messages from DON to LVN D revealed LVN D was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify.
- In-service training and verbal assessment for LVN E prior to her shift on changes of condition and the need to notify providers, including a PowerPoint on CHF management.
- In-service training and verbal quiz for LVN F prior to her shift on changes of condition, who to notify, weight gain, CHF management including s/s and concerns to look for.
- Ongoing training to any oncoming agency, PRN, or new staff.
- Review completed on all current CHF residents and there were no concerns with the orders and none required to be seen by a CHF clinic at the time of review.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with insulin-dependent type 2 DM and mild cognitive impairment had a rapid BG drop after receiving sliding scale insulin. The resident reported fear of overnight hypoglycemia and requested BG checks every 2 hours, but the record did not show overnight monitoring, reassessment, or follow-up. Staff later stated the night nurse was notified, while the resident said BG was not checked again until breakfast.
Failure to provide ordered wound care and aspiration precautions: A resident returned from a dermatology procedure with biopsy-site dressings and the chart lacked documentation of assessment or wound care, while the dressings remained in place and undated during observations. The same resident also had dysphagia with a FEES showing silent penetration with straw sips and an order for no straws, yet was observed drinking water from a cup with a straw; the SLP and DON confirmed the no-straw precaution and expectation to follow physician orders.
Failure to Monitor Ordered Vital Signs: A resident with COPD, chronic respiratory failure with hypoxia, and CHF had a provider order for daily vital signs, but the MAR showed an O2 sat of 87% with no follow-up vitals documented and another day with no vitals documented at all. Nursing notes did not show follow-up monitoring or documentation of the low O2 reading, and the CNO stated vitals were recorded on the night shift but not entered into the record or explained when the day-shift vitals were not completed as ordered.
Medication Administered Despite Hold Parameters: A resident with HTN and hyperlipidemia had an order for midodrine with BP hold parameters, but licensed nurses administered the medication multiple times even when the resident's BP met or exceeded the ordered limits. MAR review showed doses were given despite systolic and/or diastolic readings at or above the hold threshold, and the NHA acknowledged the medication was administered contrary to the physician's parameters.
Failure to assess and report abnormal blood glucose and document change in condition: The facility did not notify the MD of abnormal CBG results or assess for hypo/hyperglycemia for two residents with DM who had insulin orders and abnormal readings, including low and high values. The record also showed inaccurate documentation for another resident with a bruise of unknown origin that was monitored briefly and then no longer documented.
A facility failed to notify the provider about a resident’s weight changes per physician order. The resident had CAD, HF, HTN, and dementia, and the record showed weight fluctuations of 4 lbs and 5 lbs, but there was no evidence the provider was updated. The DON confirmed the provider was never notified and stated the provider should have been informed per the order.
Failure to Monitor Blood Glucose After Rapid Drop
Penalty
Summary
The facility failed to provide the care and services needed to safely manage diabetes for one resident with insulin-dependent type 2 diabetes and mild cognitive impairment. The resident’s care plan directed staff to monitor for signs and symptoms of high and low blood sugar, check blood glucose as ordered, administer scheduled and sliding scale insulin as ordered, encourage bedtime diabetic snacks, and provide ongoing diabetic foot care. On 7/15/26 at 12:25 a.m., the resident had a blood glucose of 330 before dinner and received 4 units of sliding scale insulin as ordered. The resident expressed concern about receiving the full insulin dose because of fear that blood sugar would drop during the night. About one hour later, the resident’s blood glucose decreased to 97. Staff gave 15 grams of carbohydrates and one glass of juice, and the blood glucose increased to 160. The resident then requested blood glucose checks every two hours during the night because of fear that blood sugar would fall below 50, and the nurse documented that the night nurse was notified. However, the medical record did not identify blood glucose monitoring, reassessment, or follow-up during the night. During interviews, the resident stated staff did not check blood sugar until breakfast the next morning and said, "They don't like checking it." Staff and the DON stated residents’ concerns should be documented and reassurance provided when blood sugar concerns were expressed.
Failure to Provide Ordered Wound Care and Aspiration Precautions
Penalty
Summary
The facility failed to provide timely post-procedure wound care for a resident who returned from a dermatology visit after a skin growth evaluation and treatment. The resident came back with dressings covering biopsy sites on the head and face, and the dermatology visit summary instructed staff to allow the pressure dressing to remain in place for 24 hours, then remove it, clean the wound daily with mild soap and water, pat dry, apply white petrolatum, and cover with a Band-Aid until healed. During observations on two consecutive days, the resident was still seen in bed with the dressings on the biopsy sites, and the dressings were not dated. The record contained no documentation that the biopsy sites were assessed upon return from the procedure and no documentation that wound care was performed on either day. The facility also failed to follow physician-ordered aspiration precautions for a resident with dysphagia. A FEES showed silent penetration with straw sips of thin liquids, and the resident was ordered an easy-to-chew diet with no straws. The care plan also directed staff not to provide beverages with a straw. Despite this, the resident was observed drinking water from a cup containing a straw. A CNA stated, "Well how else are we supposed to give him a water cup, we have to provide water." The SLP confirmed the FEES findings and the no-straw precaution, and the Medical Director stated he expected staff to follow physician orders and aspiration precautions for residents with dysphagia.
Failure to Monitor Ordered Vital Signs
Penalty
Summary
The facility failed to monitor vital signs as ordered by the physician for Resident #46, who was admitted with multiple diagnoses including COPD with acute exacerbation, chronic respiratory failure with hypoxia, and congestive heart failure. The facility policy titled Vital Signs stated that vital signs are to be taken as ordered by the provider and documented immediately after measurement, and that abnormal or concerning vital signs must be reported to the licensed nurse for assessment and intervention. A physician order dated 5/19/26 directed that Resident #46's vital signs be taken once daily during the day shift. The June 2026 MAR documented an oxygen saturation of 87% on 6/5/26 with no follow-up vital signs documented, and no vital signs documented on 6/6/26. The resident's nursing progress notes did not document follow-up vital sign monitoring or that the oxygen saturation was below 88%. The CNO stated that there was no documentation of follow-up measures or monitoring related to the low oxygen reading on 6/5/26, and that on 6/6/26 the night shift recorded vitals but did not enter them into the medical record or document why the vitals were not taken during the day shift as ordered.
Medication Administered Despite Hold Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring licensed nurses administered medications according to physician-ordered parameters for one resident. The resident had diagnoses including hypertension and hyperlipidemia. A physician order dated June 24, 2026, directed midodrine 10 mg by mouth three times daily, with instructions to hold the medication if systolic blood pressure was greater than or equal to 120 mmHg or if diastolic blood pressure was greater than or equal to 80 mmHg. Review of the medication administration record and documented blood pressure readings showed staff administered midodrine on multiple occasions even though the resident's blood pressure met or exceeded the ordered hold parameters. The medication was given when blood pressure readings included 125/72, 125/74, 122/80, 112/80, 126/66, 122/68, 126/68, and 126/68. During an interview, the Nursing Home Administrator acknowledged that staff administered the medication despite blood pressure readings that met the physician's ordered parameters requiring the medication to be withheld.
Failure to Assess and Report Abnormal Blood Glucose and Document Resident Change in Condition
Penalty
Summary
The facility failed to notify the physician of increased and decreased capillary blood glucose (CBG) levels and failed to assess residents for hyperglycemia and hypoglycemia, as well as changes in physical assessment, for three residents. Facility policy for hypoglycemia required timely initiation of emergency treatment using approved protocols, and the general documentation policy required accurate, timely documentation of resident status, interventions, and notification of appropriate parties. The facility did not have a specific hyperglycemia policy and relied on physician orders for parameters. Resident R3 had diagnoses including hypertension, diabetes, cerebrovascular accident, and dementia. Physician orders included Lantus 30 units at bedtime and Novolog 6 units with meals, along with sliding scale insulin. The eMAR showed CBG readings of 70 and 67, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified of the abnormal results. Resident R137 had diagnoses including hypertension, diabetes, muscle weakness, and cognitive communication deficit. Orders included checking blood sugars as needed for signs and symptoms of hypo- or hyperglycemia, rechecking blood sugars over 350 in 4 hours, fasting blood sugars every morning, post-prandial blood sugars, and Novolog 25 units with breakfast and lunch plus sliding scale coverage. The eMAR showed blood glucose values of LOW, 432, 45, and 0, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified. Resident R11’s record showed a bruise to the left eye/brow with unknown origin, continued monitoring notes, and then no further documentation about whether the bruise resolved; the Nursing Home Administrator confirmed the facility failed to document accurately for this resident.
Failure to Notify Provider of Significant Weight Changes
Penalty
Summary
The facility failed to update the provider about resident R8’s weight changes per physician order. R8’s record showed diagnoses including coronary artery disease, heart failure, hypertension, and dementia, and the annual MDS indicated R8 was mildly cognitively impaired. A physician order dated 7-9-26 directed daily weights and to report a change of 3 lbs overnight. The weight record showed a 4 lb decrease from 153.5 lbs to 149.5 lbs and a 5 lb increase from 148.5 lbs to 153.5 lbs, but the medical record lacked evidence that the provider was ever notified of these changes. The DON confirmed by email that the provider was never updated, and later stated the provider should have been notified per the order.
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