Failure to Adhere to Heart Failure Care Standards and Monitoring
Penalty
Summary
A deficiency was identified in the facility's failure to provide care in accordance with professional standards for a resident diagnosed with hypertensive heart disease with heart failure, diabetes mellitus, and hyperlipidemia. The resident's care plan included interventions such as encouraging a low fat, low salt diet and obtaining lab tests as needed. Despite this, the resident experienced a significant weight gain of over 10% in less than a month, which was not part of a physician-prescribed regimen. The facility's policy required daily assessment of residents with heart failure for lung sounds, respiratory status, and pedal pulses, as well as prompt provider notification of significant weight changes. However, the resident was only weighed monthly, and there was no documentation of daily or weekly weight monitoring, nor evidence of required nursing assessments for heart failure. Further review revealed the absence of physician orders for dietary restrictions, fluid restriction, intake and output monitoring, or daily weights, despite these being indicated in the care plan and facility policy. Interviews with facility staff confirmed that the necessary assessments and monitoring were not being conducted, and relevant policies such as the Heart Failure Policy and Resident Assessment Policy were not provided when requested. The lack of adherence to established protocols and missing documentation contributed to the deficiency in meeting professional standards of care for the resident with heart failure.