F0684

G

Failure to Monitor and Treat Fluid Overload in Resident With CHF and CKD

Chicago, Illinois Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to identify and treat symptoms of altered cardiovascular status and fluid overload for a resident with chronic diastolic heart failure, essential hypertension, and stage 3 chronic kidney disease, resulting in a 53.4‑pound (48%) weight gain over six months and subsequent hospitalization for acute decompensated heart failure. The resident also had diagnoses including Alzheimer’s disease, shortness of breath, and obstructive sleep apnea, with moderately impaired cognition per the MDS. Over time, the resident’s functional status declined, as reflected in MDS Section GG toileting hygiene coding changing from partial/moderate assistance to dependent, and staff observations that the resident went from being able to get out of bed and use the bathroom with assistance to becoming bedbound, dependent on diapers, and visibly swollen over the entire body.

Weight trends documented in the record show a progressive increase from 144.4 lbs in early February to 203.8 lbs by early August, with a progress note on 08/09/25 explicitly stating that the resident was re‑admitted following a CHF hospitalization and had triggered for significant weight gain of 7.6% in one month and 48% in six months, likely fluid‑related given the history of CHF and CKD3B. A 07/29/25 internal medicine progress note identified weight gain of over 55 lbs in six months, noted that nutritional intake had been closely monitored and Med Pass BID supplementation was under review, and directed that cardiology be consulted for volume status and cardiac contribution, intake/output be monitored, diuretics adjusted if needed, daily weights be obtained, and nephrology referral considered. However, daily weights and intake/output records were not found, no nephrology consult was ever ordered, and there were no documented diuretic adjustments. The cardiology consult order was not placed until 08/06/25, after a change in condition and hospitalization, despite earlier documentation that cardiology consultation was needed.

Interdisciplinary and nursing documentation repeatedly identified concerns about fluid retention and edema without corresponding timely medical follow‑through. On 06/30/25, a visit note cited weight gain, increased need for ADL assistance, wheelchair dependence, and the need to monitor for CHF/CKD signs. On 07/27/25, the nutrition note documented a total gain of 55.4 lbs over six months, bilateral lower extremity swelling, concern for fluid retention, and referrals to the NP for labs and to cardiology for fluid status and CHF management, with instructions to continue monitoring weight and edema. The registered dietician later stated that the resident’s appetite had not changed, that edema was driving the weight gain, that the 48% weight gain was extremely significant and concerning, and that she communicated concerns to the ADON but never spoke directly with a physician. A CNA reported that as the resident gained weight, she experienced a lot of pain, no longer wanted to get out of bed, and became dependent on diapers, with visible swelling of the whole body.

Nursing and provider interviews and records further demonstrate delayed response to significant edema and weight gain. An RN stated that at the beginning of her shift she noticed the resident’s significant edema and called the doctor, and while on the phone was informed that the resident had lost consciousness, leading to a 911 transfer. A progress note on 08/05/25 documented peripheral edema and a temporary loss of consciousness while eating, with the resident sent out via 911 for further evaluation. Hospital records from 08/10/25 and 08/13/25 documented cardiomegaly, pulmonary vascular congestion, pulmonary edema, bilateral pleural effusions, bibasilar atelectasis, decreased breath sounds with rales, bilateral leg edema, and a 15‑pound weight loss with diuresis since admission. The NP stated that weight gain had been concerning since March, that she wanted cardiology involvement but appointments take time, and that she assumed the resident had functional decline due to the weight gain and pressure from the weight. The transportation coordinator reported that no appointments were scheduled for the resident in July, and that when informed on 08/07/25 to schedule a cardiology appointment “ASAP in 1 week,” the appointment was set for October. Despite care plan directives to monitor and report changes in lung sounds, edema, weight, and signs of fluid overload related to renal insufficiency and altered cardiovascular status, the facility did not implement timely monitoring and specialist follow‑up as ordered and care‑planned, contributing to the resident’s acute decompensated heart failure and hospitalization.