F0684

J

Failure to Recognize and Act on Rapid Weight Gain and Edema as Change in Condition

Wurtland, Kentucky Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to recognize and respond to a significant change in condition for one resident, including substantial weight gain and edema, in accordance with its own policies and the resident’s care plan. The resident was admitted for short-term rehabilitation following a serious illness with sepsis and a spinal abscess, with hospital diagnoses including atrial fibrillation, coronary artery disease, pneumonia, and stable shortness of breath at discharge. On admission, the facility documented diagnoses of pneumonia, nontraumatic subdural hemorrhage, and primary hypertension, and the MDS reflected atrial fibrillation, hypertension, moderate cognitive impairment (BIMS score of 8/15), IV access, and shortness of breath when lying flat. The care plan directed staff to weigh the resident as ordered, notify the physician of significant weight changes, and, after an update, to observe and document signs and symptoms of cardiac dysfunction such as shortness of breath, abnormal lung sounds, decreased urine output, edema, and changes in mental status, and to notify the physician of abnormal findings.

The facility’s policies on Change in Condition and Weight Monitoring required staff to notify the physician or nurse practitioner for abnormal weights and significant changes, to re-weigh residents for weight changes of 3 pounds or more in one day or 5 pounds in one week, and to notify the physician, resident, and representative of such changes. Despite these policies, the resident’s weight increased from an admission weight of 252.8 pounds to 259 pounds within four days, then to 267 pounds within nine days, and to 270 pounds within 13 days, for a total gain of 17.2 pounds. The DON entered the 259‑pound weight and acknowledged later that this represented a clinically significant gain per policy but did not assess the resident or notify the APRN. LPN1 entered the 267‑pound weight but did not document any re‑weigh, assessment, or provider notification related to this gain and could not recall taking any such actions, stating that if she had notified a provider she would have charted it.

During this period of rapid weight gain, clinical signs consistent with fluid accumulation were present but not consistently recognized or acted upon as a change in condition. A Health Status Note documented that a family member reported the resident’s right hand swelling, increased confusion from baseline, and complaints of shortness of breath; LPN5 documented these findings and notified the APRN, who ordered continued monitoring only, without further specified parameters. Skilled nursing assessments on two dates documented shortness of breath or labored breathing with exertion and when lying flat, need for supplemental O2 and head-of-bed elevation, and edema in both lower extremities, yet the corresponding progress notes from admission through the date of transfer contained no documentation of edema or shortness of breath and no evidence that staff recognized the weight gain as a significant change in status or notified the physician as required. On the thirteenth day, LPN4 documented +3 to +4 pitting edema in all four extremities, marked scrotal swelling, and shortness of breath after the family member again raised concerns, and EMS later assessed the resident as in acute respiratory distress with crackles/wheezing and pitting edema in all extremities. The APRN and Medical Director both stated they relied on nursing staff to notify them of rapid weight gain and changes in assessment findings, and the DON confirmed she could find no evidence that staff identified the resident’s weight gain as a potential change in condition or notified the APRN after the initial report of arm swelling, leading surveyors to cite the facility under F684 for failing to provide care in accordance with policies, care plan, and professional standards.