Failure to Monitor and Notify Physician of Fluid Overload in CHF Patient
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and monitor a resident with congestive heart failure (CHF) for signs and symptoms of fluid overload, despite the resident being on diuretics and requiring daily weights. The resident experienced a significant weight gain of 16 pounds over 10 days, with daily weights showing a steady increase. There was no evidence that the facility compared fluid intake with urine output, nor did they conduct comprehensive assessments to determine if the weight gain was due to fluid retention or nutritional factors. Additionally, the facility did not notify the physician of the resident's weight gain, which exceeded the facility's own parameters for physician notification. The resident's care plan and physician orders included daily weights and fluid restriction, but lacked specific parameters for when to notify the physician or interventions for managing fluid volume status. Staff interviews revealed that nurses and aides did not consistently assess for edema, listen to lung sounds, or document and report changes in the resident's condition, such as increased weight, edema, or shortness of breath. Several staff members noted the resident appeared puffy or had increased edema, but these observations were not communicated to the nursing or medical team in a timely manner. The facility's electronic medical record system flagged the weight gain only after a significant increase had already occurred. As a result of these failures, the resident developed acute kidney injury and worsening CHF, ultimately requiring hospitalization for diuresis. The hospital record indicated the resident had fluid retention, acute kidney injury, and was discharged home on hospice care. The lack of timely assessment, monitoring, and physician notification directly contributed to the resident's decline and the identification of Immediate Jeopardy by surveyors.
Removal Plan
- Identification of like residents at-risk.
- Addition of baseline weight to daily weight orders along with parameters for weight gain and to contact the physician for a specified increase, edema assessments with baseline edema listed in physician's order, lung sounds added to interventions and care plans updated.
- Developed a new significant weight change policy and reviewed other applicable policies such as weight management and vital signs.
- Developed a fluid restriction guideline/worksheet.
- New admission order set created for residents admitting with diagnosis of CHF, edema, use of diuretics, and compression which includes edema checks, lung sounds, weights with specified parameters.
- Residents who have a diagnosis of heart failure and edema, but currently not at-risk, facility added baseline weights on their weight assessment and edema checks with primary bath/skin checks.
- Clinical coordinators are responsible for assessing and monitoring the resident for a change in condition with subsequent notification of medical provider.
- Staff completed review of newly developed significant weight change policy and procedure.
- Direct education reviewing how to assess for edema along with early recognition of heart failure symptoms completed before each licensed nurse's next scheduled shift and availability of staff not regularly scheduled.
- Education also included in orientation of all newly hired staff.