Failure to Incorporate Diuretic Therapy Into Resident Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to individualize a resident’s comprehensive care plan by omitting the resident’s diuretic medication therapy and related monitoring needs. The resident had moderately impaired cognition with a BIMS score of 12 and required varying levels of assistance with ADLs and mobility. Diagnoses included atrial fibrillation, prior stroke, traumatic brain injury, and a narrowed heart valve. The resident received a diuretic during a hospital stay, with discharge orders directing its use for a defined period. Upon admission, the facility physician discontinued the diuretic, but subsequent nursing documentation showed the resident developed increased bilateral lower extremity edema, shortness of breath with exertion, and phlegm, prompting provider notification. Following these changes, nursing staff documented new diuretic orders due to the resident’s increased weight and edema. Despite this, the care plan revised on a later date did not include the resident’s diuretic therapy or provide staff with directions on what to monitor or when to intervene. Multiple nursing staff and the DON stated that changes in treatment, including medication changes, should be reflected in the care plan within 24–48 hours of initiation, and that any nurse could update the care plan, with the MDS Coordinator designated to manage medication updates. The facility’s Comprehensive Care Plan Process policy required that the care plan describe services furnished to attain or maintain the resident’s highest practicable well-being, but the resident’s care plan lacked the diuretic-related interventions and monitoring despite the new orders and documented clinical changes.
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