Failure to Implement and Document Care Plan Interventions for Edema Management
Penalty
Summary
Facility staff failed to implement and follow the care plan for a resident with a history of chronic obstructive pulmonary disease, heart failure, and type II diabetes mellitus, who was admitted with significant pitting edema in both lower extremities and the left upper extremity. The care plan, initiated in June 2024, specified that the resident should wear TED hose stockings to address the risk of fluid volume overload and reduce edema, as ordered by the physician. However, observations and interviews revealed that the resident was not wearing the prescribed TED hose, and staff were unable to confirm when they were last applied. Record reviews, including the medication administration record, did not show documentation that TED hose were being applied as ordered. Multiple staff interviews confirmed that the resident was not wearing the TED hose and that licensed nurses were not consistently assessing or documenting the resident's pitting edema. The resident reported not understanding why the TED hose were not being applied, and staff acknowledged the importance of this intervention for managing edema. The facility's policy and procedure on care planning required that comprehensive, person-centered care plans be developed and implemented based on assessed needs, and that residents receive the services and items included in their care plans. The failure to apply TED hose as ordered and to assess and document edema as required by the care plan constituted a failure to follow both physician orders and facility policy, resulting in the identified deficiency.