F0656

J

Failure to Implement Comprehensive Cardiac and Weight Monitoring Care Plan

Wurtland, Kentucky Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, resident-specific care plan that addressed all identified needs, including monitoring and response to significant weight changes and potential complications from continuous IV fluids. The resident was admitted with diagnoses including pneumonia, nontraumatic subdural hemorrhage, atrial fibrillation, coronary artery disease, and hypertension, and had an IV access for antibiotics. The care plan included an intervention for nurses to weigh the resident as ordered and notify the physician of significant weight changes, and was later updated to identify risk for cardiac dysfunction with instructions to observe for signs such as shortness of breath, cough, abnormal lung sounds, change in mental status, activity intolerance, decreased urine output, edema, dizziness, and weakness, document abnormal findings, and notify the physician. However, the care plan did not include resident-specific interventions related to potential complications from continuously infusing IV fluids.

The facility’s own Weight Monitoring policy required staff to notify the physician of a weight gain or loss of three pounds within one week, and the physician’s orders for the resident included weekly weights. The weight records showed that the resident’s weight increased from the admission weight to 259 pounds within four days (a gain of 6.2 pounds), then to 267 pounds within nine days (a gain of 14.2 pounds), and then to 270 pounds within 13 days (a total gain of 17.2 pounds). Despite these significant weight gains, there was no documented evidence that staff implemented the care plan interventions by notifying the physician of the changes between the admission date and the date of the last recorded weight. Interviews with nursing staff indicated that they did not recall notifying the physician about the weight gain, and one LPN acknowledged she did not always directly assess residents for edema, despite the care plan requiring observation for edema as a sign of cardiac dysfunction.

A family member reported observing progressive swelling of the resident’s legs, feet, and scrotum during daily visits and stated he felt staff ignored his concerns about the edema. He indicated that he requested the resident be sent to the hospital due to his concerns about the swelling, and that the transfer occurred only after his request. The APRN stated that staff did not notify him of changes in assessment findings, including the resident’s weight gain, until the date the resident was ultimately sent to the hospital. The facility’s leadership, including the DON and Administrator, stated they expected staff to follow care plans, including interventions to notify the physician of significant weight changes and edema, but could not explain why staff failed to implement the care-planned interventions for this resident. The combination of incomplete care planning for continuous IV fluids and failure to implement existing care plan interventions and notification requirements led to the cited deficiency under F656 for not ensuring a comprehensive, resident-centered care plan was developed and implemented.

Hospital documentation showed that the resident arrived on the inpatient unit in the evening and was later found unresponsive with pulseless electrical activity and agonal breathing, with a Code Blue initiated and the resident subsequently pronounced expired. The hospital admission diagnoses included fluid overload and myocardial infarction. The surveyors concluded that the facility’s failure to implement the care plan interventions and notify the physician beginning several days prior resulted in a delay in intervention and treatment for the resident, and Immediate Jeopardy was identified related to the deficient practice in comprehensive care planning and implementation.