Failure to Follow Professional Standards for Assessment and Monitoring of CHF and Cellulitis
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice for two residents. One resident with a history of congestive heart failure (CHF) did not receive adequate assessment and monitoring of edema. Despite orders and care plans specifying the need for daily weights, lung sound assessments, and monitoring for signs of fluid overload, there were significant lapses. Weights were not documented for a 10-day period during which the resident experienced a notable weight gain, and provider notification only occurred after this increase. Routine assessments did not include lung sounds, pedal pulses, or proper edema measurements such as circumference and length, as recommended by professional guidelines. Staff interviews revealed a lack of awareness and implementation of manufacturer instructions for Tubi grip sizing and use, and no standard practice was in place for edema assessment. Another resident with a diagnosis of cellulitis did not receive adequate assessment and monitoring of the condition. The care plan required regular skin inspections, but the facility could not provide documentation of nail care and inspection as ordered. After the resident developed pain and drainage from the toenail, there was no consistent documentation of erythema, tenderness, drainage, or other signs of infection before or after the diagnosis of cellulitis. The area of erythema was not marked to monitor for spread, contrary to current standards of practice. Staff interviews confirmed that there was no standard protocol for marking or monitoring the area, and assessments were only performed if specifically ordered by the provider. In both cases, the Director of Nursing and nursing staff acknowledged the absence of facility standards for assessment and monitoring of these conditions, relying instead on provider orders. This resulted in incomplete and inconsistent monitoring and documentation, which did not align with current professional standards of practice for managing CHF-related edema and cellulitis.