Failure to Monitor and Document Edema Management
Penalty
Summary
The facility failed to comprehensively monitor and assess a resident with a history of heart failure and lymphedema for edema, which prevented the determination of intervention effectiveness and the development of new interventions as needed. The resident's care plan required staff to monitor for adverse reactions to diuretics, apply and assess edema wraps and compression devices, and document skin assessments. However, weekly skin checks over a two-month period consistently indicated no edema, and the medical record lacked further assessment of the resident's left upper extremity edema during this time. Observations and interviews revealed that the resident continued to experience significant swelling in the left upper extremity, with visible puffiness and limited hand movement. Nursing staff acknowledged the chronic nature of the resident's edema but were unable to identify where this was documented in the records. One nurse noted that the edema had persisted at its current level for almost a month without documentation, and another stated that documentation of the edema was expected but not present. The facility's policy required assessments to be documented in the electronic health record, but this was not done for the resident's ongoing edema.