Failure to Implement Edema Interventions and Notify Provider for Significant Weight Gain
Penalty
Summary
The facility failed to implement physician-ordered interventions for edema management for a resident with a history of acute respiratory failure, hypertensive heart disease, and congestive heart failure. The resident's care plan required staff to monitor for signs of increased edema and weight gain, document findings, and notify the medical provider as necessary. Physician orders specified that the nurse practitioner should be updated if the resident gained 3 pounds or more in 48 hours or 5 pounds in a week. Despite documented weight increases exceeding these thresholds over several days, there was no evidence that staff identified or reported the significant weight gain or associated edema to the provider in a timely manner. Nursing documentation did not reflect a comprehensive assessment or implementation of new interventions in response to the resident's worsening edema and new onset of pain. Observations confirmed the resident exhibited visible swelling in the face, hands, and legs, and interviews with nursing staff and administration revealed that the required monitoring and notification procedures were not followed. The nurse practitioner was unaware of the specific physician order to be notified of significant weight gain and indicated that earlier intervention would have been expected. Facility policy required standardized assessment and provider notification for untoward results related to edema, but this was not carried out as directed.