Failure to Provide Heart Failure Treatment and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and services related to heart failure for one resident who had a history of atrial fibrillation, COPD, and diabetes. Despite a significant and rapid weight gain of 17 pounds over three days, and subsequent continued weight increases, there was no documentation in the clinical record or progress notes that this change was recognized or addressed by nursing or medical staff. The resident's care plan did not include goals or interventions for heart failure after the diagnosis was made, and the diagnosis was not added to the facility's diagnosis list. Orders for weights and diuretic medication (Lasix) were present, but the monitoring and response to the resident's changing condition were inadequate. Multiple provider and nursing notes failed to reference or address the resident's substantial weight gain and associated symptoms, such as increased lower extremity edema, respiratory distress, and confusion. The facility's staff did not document or communicate the full extent of the weight gain to the physician, and there was a lack of timely intervention or adjustment of the care plan in response to the resident's deteriorating condition. The deficiency was confirmed by the Nursing Home Administrator and Director of Nursing during interviews.