Failure to Address Edema in Resident Care Plan
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that a resident's care plan was comprehensively written to address all of her needs, specifically omitting interventions and treatment planning for edema. The resident, who was admitted following a stroke with additional diagnoses of diabetes, hypertension, and COPD, reported increased swelling in her right leg that was only partially relieved by elevating her legs. Despite having multiple physician orders for diuretics to treat edema, the care plan did not include any documentation or interventions related to this condition. The Director of Nursing confirmed that the resident's edema treatment and interventions were not included in the care plan, acknowledging that they should have been.