Failure to Accurately Monitor and Document CHF Management
Penalty
Summary
The facility failed to accurately assess and manage the diagnosis of congestive heart failure (CHF) for one resident with a history of morbid obesity and recent hospitalization for acute CHF exacerbation. Upon admission, the resident was alert, oriented, and able to communicate needs. Hospital discharge instructions and provider progress notes indicated the need for daily or at least weekly weight monitoring to assess for fluid retention, a critical aspect of CHF management. However, the facility order only specified weekly weights, and documentation showed repeated identical weights over several weeks, with no evidence that actual weights were obtained. When the resident refused a weight, there were no documented re-attempts to obtain it, and staff interviews revealed logistical barriers to weighing the resident, such as equipment incompatibility and resident discomfort with the Hoyer lift. The resident reported not being weighed for an extended period and expressed understanding of the importance of weight monitoring for CHF. Further review and interviews indicated that staff may have been copying and pasting previous weights rather than obtaining accurate measurements, as the documented weights remained unchanged week after week. The Director of Nursing confirmed that staff should continue to attempt to obtain weights after refusals and that weight monitoring protocols should be adjusted based on stability. The Administrator acknowledged the likelihood of inaccurate documentation. An observed weight obtained during the survey showed a significant increase from the resident's hospital discharge weight, and a previously obtained weight referenced by the resident was not documented in the medical record.