Failure to Follow Physician Orders and Care Plan for Edema Management
Penalty
Summary
Staff failed to provide care according to physician orders, resident preferences, and established standards of practice for two residents with edema. For one resident with a history of non-Hodgkin lymphoma, varicose veins, hypertension, and cardiovascular disease, staff did not document follow-up regarding observed swelling in the feet, ankles, and legs. Although the resident was observed wearing Tubi grips on both lower extremities, there was no physician order for their use, and the care plan did not address the use of Tubi grips or the management of edema. Multiple staff interviews confirmed the absence of an order and lack of care plan documentation for Tubi grips, despite their regular application by CNAs. For another resident with diagnoses including edema, hypertension, and chronic respiratory failure, staff failed to consistently complete and document daily weights as ordered by the physician. The resident's care plan was not updated to reflect new orders for fluid restriction, Tubi grips, and Lasix. Review of the Medication Administration Record (MAR) revealed multiple days where weights were neither documented nor refusals recorded, and there was no documentation of physician notification when significant weight changes occurred. The resident reported ongoing swelling, difficulty walking, and issues with shoe fit due to edema, and expressed that daily weights were not being performed as expected. Interviews with various staff members, including CNAs, LPNs, the MDS Coordinator, the DON, and the Administrator, confirmed that Tubi grips require a physician order and should be included in the care plan, as should edema management and daily weights. Staff acknowledged that daily weights were the responsibility of CNAs, with the charge nurse providing a list of residents requiring weights. Despite these expectations, documentation and care planning were not completed as required, resulting in deficiencies in the provision of care for residents with edema.