Failure to Timely Identify and Assess New Onset Edema in Resident with Heart Failure
Penalty
Summary
A deficiency occurred when staff failed to identify and assess the new onset of bilateral lower extremity edema in a resident with chronic heart failure, chronic kidney disease, hypertension, atrial fibrillation, and a malignant neoplasm of the pancreas. The resident was admitted for palliative care and had no edema upon admission, as documented in the initial nursing assessment and confirmed by a nurse practitioner. The facility's policy required regular inspection and monitoring for edema in residents with heart failure, but this was not followed. The resident began experiencing swelling in both lower extremities, which was observed by the surveyor and reported by the resident as a new development. Despite visible signs of swelling and the resident's own report of the issue, the certified nurse aide who assisted with bathing did not notify nursing staff, believing the swelling was not new. The assigned nurse was unaware of the edema and did not assess or document the change in condition. There was no evidence in the clinical record that an assessment of the edema was performed in a timely manner after the onset of symptoms. Multiple interviews revealed that neither the physician nor the physician assistant assessed the resident promptly after being notified of the swelling. The nurse responsible for the resident did not complete a required nursing note or health status note regarding the change in condition. The delay in assessment and lack of timely communication and documentation resulted in the resident's edema going unaddressed for several days, contrary to facility policy and standard care expectations for residents with heart failure.