Failure to Follow Discharge Orders and Monitor Heart Failure Resident
Penalty
Summary
The facility failed to monitor and adequately treat a resident with a diagnosis of heart failure and severe cognitive impairment. Upon admission, the resident's hospital discharge instructions included orders to continue home Lasix (furosemide), monitor daily weights, and notify the provider of a weight gain or loss of 3 pounds on two consecutive days, as well as signs of increased difficulty breathing or swelling. The clinical record did not show evidence that the Lasix was continued as directed, nor that daily weights were consistently obtained. Specifically, there were multiple days where no weight was recorded, and the resident was not weighed for 19 out of 22 days during the review period. Despite clear orders, the facility did not document administration of furosemide or consistent monitoring of the resident's weight. The resident experienced a significant weight gain of 12 pounds and developed new onset non-pitting and later pitting edema in both feet, as well as other symptoms such as shortness of breath, wheezing, and a new heart murmur. There was no evidence that the provider was notified of the significant weight gain or the new symptoms as required by the discharge instructions and physician orders. Ultimately, the resident's condition worsened, resulting in hospitalization for treatment of diastolic congestive heart failure. Interviews with facility staff confirmed that the discharge instructions were not fully implemented, and that communication issues and incomplete transfer of medication orders contributed to the failure to provide appropriate care and monitoring for the resident.