F0684

D

Failure to Ongoingly Assess CHF Resident After Respiratory and Edema Changes

West Des Moines, Iowa Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ongoing assessments and interventions for a resident with a history of CHF and multiple cardiac and neurologic diagnoses. The resident’s MDS showed moderately impaired cognition, independence with eating, and need for assistance with transfers and ADLs. Diagnoses included AFib, prior stroke, traumatic brain injury, and a narrowed heart valve, and the resident was receiving a diuretic. Clinical documentation showed progressive edema and respiratory concerns: 3+ edema in the left arm, increased edema in both lower extremities, and shortness of breath with exertion and phlegm. During a care conference, the OT reported arm edema affecting the resident’s ability to perform ADLs, and the DON reviewed weights and medications. Subsequent nursing notes documented increased weight, fluid buildup in the forearms, audible wheezing, and a family request to change the diuretic, which led to a new diuretic order.

Despite these documented changes in condition, including ongoing wheezing noted in the early morning hours, the clinical record lacked further assessments of the resident’s lung sounds after that point. Staff interviews indicated that for residents with CHF, nurses were expected to assess daily weights, lung status, edema, breathing, congestion, and shortness of breath. The facility’s Change of Condition Monitoring Process policy defined a significant change in status as requiring immediate nurse assessment, intervention, documentation, and physician notification and follow-up. However, the record did not contain continued respiratory assessments following the last documented wheezing, indicating a failure to follow the facility’s own assessment and monitoring expectations for a resident with CHF and documented respiratory and edema changes.