Failure to Assess and Address Edema and Weight Gain in Resident with Complex Medical Needs
Penalty
Summary
The facility failed to complete thorough assessments and provide appropriate care for a resident with significant medical conditions, including liver disease, dementia, acute kidney failure, ascites, localized edema, and severe protein-calorie malnutrition. The resident experienced a substantial weight gain over the course of her stay, with her weight increasing from 85.4 lbs at admission to 106 lbs at discharge. Despite this significant change, the facility attributed the weight gain to improved nutrition and did not adequately investigate or address the possibility of fluid retention, even though the resident had a history of ascites and generalized edema (anasarca). Family members repeatedly raised concerns to staff about the resident's increasing abdominal size and swelling in her lower legs, but these concerns were dismissed or minimized by both staff and the facility physician. Compression stockings were applied to the resident, resulting in hematomas and significant discomfort, leading the family to refuse further use. The facility's documentation of the resident's edema was inconsistent, with some assessments noting its presence and others, including one on the day of transfer to the emergency department, indicating its absence. However, emergency department records from the same day documented 2 to 3 plus pitting edema in the resident's lower extremities, as well as a blood blister and cold extremities. The resident's condition deteriorated to the point that her primary care physician arranged for her transfer to the emergency department, where she was found to have significant fluid accumulation and subsequently had three liters of fluid drained from her abdomen at an acute care hospital. Interviews with facility staff revealed a lack of awareness regarding the resident's abdominal swelling and weight gain, and the facility lacked a specific policy addressing the management of such changes in condition. The failure to conduct thorough assessments and respond appropriately to the resident's symptoms and family concerns led to a deficiency in the quality of care provided.