Failure to Develop and Implement Edema Management Care Plans and Monitoring
Penalty
Summary
The facility failed to develop and implement care plan goals and interventions for two residents with edema, as well as to monitor their condition as required. One resident, who had diagnoses including lymphedema and osteomyelitis, was admitted with significant lower leg edema and a surgical incision on the left heel. The care plan addressed skin impairment and general skin care but did not include specific interventions or monitoring for lymphedema or lower leg edema. Although an order was given for Tubi-grips to manage edema, the resident consistently refused them, and no alternative interventions or monitoring were documented. Observations showed persistent edema and discoloration, and the resident reported a lack of other measures to address swelling. Another resident, admitted with high blood pressure and irregular heartbeat, also exhibited lower extremity edema. This resident had received Lasix, which was later discontinued with instructions for monitoring blood pressure and fluid status, but documentation showed only one progress note during the monitoring period and no evidence of edema monitoring in the medication administration records. The care plan did not address the resident's edema, and repeated observations showed ongoing swelling, redness, and fluid leakage from the legs. Staff interviews confirmed that interventions such as compression stockings, elevation, and monitoring should have been in place, but these were not documented or observed. The Director of Nursing and other staff acknowledged that care plans and monitoring for edema were lacking for both residents. The facility did not have a specific policy for lymphedema and edema management, relying instead on standard practices. The absence of individualized care planning and monitoring for edema in these cases constituted a failure to provide appropriate treatment and care according to orders, resident preferences, and goals.