Failure to Provide Timely Edema Management and Follow-Up on Specialist Referrals
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards for two residents. One resident with a history of chronic obstructive pulmonary disease, hyperlipidemia, and hypertension developed new onset bilateral lower extremity edema. Despite a provider's order for Torsemide and recommendations to elevate the resident's legs, the care plan was not updated, daily weights were not consistently obtained, and there was no documented reassessment of the edema or implementation of interventions such as leg elevation or compression socks. Staff interviews confirmed that expected monitoring and interventions were not carried out, and the treatment administration record did not reflect necessary actions to address the edema. Another resident with a traumatic brain injury and speech deficits had an after-visit summary from neurology recommending referrals for physical therapy, rheumatology, and speech therapy. The facility did not follow up on these referrals or schedule the recommended appointments. Staff interviews revealed a lack of communication and follow-through due to staffing issues and unclear responsibilities between social services and care coordinators. This deficiency was noted as a repeat issue from a previous survey.