Failure to Assess and Address Edema, Weight Gain, and Complete Physician Orders
Penalty
Summary
The facility failed to assess and address significant weight gain, edema, and to follow through with physician orders for a resident with multiple comorbidities, including stage III chronic kidney disease, diabetes, morbid obesity, and a cardiac murmur. The resident, who was cognitively intact, reported a recent hospitalization for high ammonia levels and expressed dissatisfaction that the facility did not identify the issue earlier. Despite a physician order for an ammonia lab test following her return from the hospital, there was no evidence in the electronic medical record that the test was completed, and staff were unaware of the order. Observations revealed the resident had 1-2+ pitting edema in her lower extremities and swollen hands, with a notable weight gain of over 22 pounds within approximately two months. Nursing staff and management were not aware of the weight gain or edema until prompted, and there was no documentation of reweighing, provider notification, or resident education regarding food and fluid intake as expected by facility policy. The care plan included daily foot inspections and lab monitoring for electrolyte imbalances, but these interventions were not effectively implemented.