Failure to Assess and Notify Provider for Skin Breakdown and CHF Monitoring
Penalty
Summary
A resident with multiple complex medical conditions, including chronic diastolic congestive heart failure (CHF), chronic respiratory failure, morbid obesity, lymphedema, and schizoaffective disorder, experienced deficiencies in care related to both skin integrity and CHF monitoring. The resident, who was cognitively intact, reported developing soreness and potential skin breakdown on her buttocks from prolonged sitting on a Hoyer sling. Despite voicing these concerns, the registered nurse did not complete a timely assessment or promptly notify the provider of the potential skin breakdown. Interviews with staff revealed that the Hoyer sling was consistently left under the resident while she was seated, and staff cited difficulty and time constraints as reasons for not removing it. The facility's own policies required daily skin monitoring and immediate provider notification for new wounds, but these procedures were not followed. Further investigation showed that the facility failed to adequately monitor and document the resident's weight as ordered by the physician, which was critical for managing her CHF. The care plan and treatment administration record specified bi-weekly weights and provider notification for significant weight changes. However, weight documentation was inconsistent, with several weeks missing entries and no evidence of refusals by the resident, despite staff claims. The facility had a Hoyer lift capable of weighing the resident during transfers, but this feature was not utilized as required. Interviews with multiple CNAs confirmed that the resident did not refuse weight checks, contradicting the assumption that refusals were the reason for missing data. The director of nursing acknowledged that staff should have followed physician orders for weight monitoring and timely provider notification. The lack of regular weight monitoring and failure to notify the provider of significant weight fluctuations meant that symptoms of CHF exacerbation were not adequately tracked. Additionally, the facility did not perform a full assessment or timely provider notification regarding the resident's change in skin condition, as required by facility policy and professional standards of practice.