Failure to Initiate Edema Interventions for Dependent Resident
Penalty
Summary
The facility failed to implement interventions to address edema for a resident with a history of localized edema and multiple complex medical conditions, including anoxic brain damage, contractures, and chronic pain. The resident, who was dependent on staff for all activities of daily living and had severely impaired cognition, was observed multiple times with dependent positioning of the arms and hands, including visible edema and a closed fist in the left hand. Despite repeated observations and assessments by nursing staff confirming the presence of pitting edema in the left hand and forearm, there were no documented interventions in the medical record to address or monitor the edema. Staff interviews confirmed the absence of any care plan or interventions related to the resident's edema.