Failure to Recognize and Respond to Heart Failure Exacerbation
Penalty
Summary
Facility staff failed to recognize and respond to symptoms indicating an exacerbation of heart failure in a resident with a history of chronic non-occlusive DVT and congestive heart failure with a reduced ejection fraction of 30 percent. The resident, who had severely impaired cognitive abilities, reported a persistent dry cough that had not improved with her usual home remedy, as well as new swelling in her right leg in addition to known left leg edema. Observations confirmed significant pitting edema in both legs, and the resident was found to be wearing non-skid socks that left indentations, with no compression hose available due to improper fit. The resident also reported not being weighed for several days and was unaware of her current weight. Staff interviews and clinical record review revealed that the resident had not been weighed as scheduled, and her symptoms of worsening heart failure, including increased edema and a cough persisting for weeks, were not promptly recognized or addressed. When the resident was finally weighed, a significant weight gain of over three pounds in one day was noted, prompting a change in her treatment plan. The delay in assessment and intervention contributed to the failure to provide appropriate care according to the resident's orders, preferences, and goals.