Failure to Notify Physician of Significant Weight Gain and Edema
Penalty
Summary
The facility failed to notify the physician as required when a resident with a history of acute respiratory failure, hypertensive heart disease, and congestive heart failure experienced significant weight gain indicative of fluid retention and edema. The resident's care plan and physician orders specifically directed staff to obtain daily weights and to notify the medical provider if there was a weight gain of 3 pounds or more in 48 hours or 5 pounds in a week. Despite documented weight increases exceeding these thresholds over several consecutive days, there was no evidence that the provider was contacted prior to a nurse practitioner visit. Nursing staff acknowledged during interviews that the provider should have been notified earlier, and the director of nursing confirmed that staff were expected to follow these orders. The resident was observed with visible swelling in the face, hands, and legs, and reported new onset of pain related to leg swelling. Although the nurse practitioner was eventually informed and took action, this did not occur until after the required notification window had passed. Facility policies required immediate notification of the provider for significant changes in condition, including weight gain and edema, but these protocols were not followed in this instance, resulting in a deficiency related to timely physician notification.