Failure to Recognize and Act on Rapid Weight Gain and Edema as Change in Condition
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.
Removal Plan
- Resident #117 was discharged.
- All current residents were re-weighed and reassessed for change of condition by the Director of Nursing Services, Assistant Director of Nursing Services, and Unit Manager, with weights reviewed for the last 6 months.
- For any significant weight changes identified, a nursing assessment was completed by the Director of Nursing Services, Assistant Director of Nursing Services, or Unit Manager with notification of the physician or nurse practitioner for orders as needed.
- All residents were reassessed and reweighed, and any changes of condition were reported to the Nurse Practitioner with orders given.
- All nurses were re-educated by the Infection Preventionist/Staff Development, Director of Nursing Services, or Assistant Director of Nursing Services regarding the policy to notify the physician or nurse practitioner of all significant weight changes and the policy on changes in condition; no nurse worked before receiving the education.
- A post-test was administered to all nurses with an expected 100% pass rate; if 100% was not achieved, re-education was provided.
- The Director of Nursing, Assistant Director of Nursing, Infection Preventionist/Staff Development, or Unit Manager will provide education until all nurses complete it.
- Education on notification of significant weight changes and changes in condition will be added to new-hire orientation for nurses and certified medication technicians.
- An ad hoc QAPI meeting was held with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and Medical Director to review the alleged deficiency, audit tools, plan, and education regarding notification of changes.
- The Director of Nursing Services, Assistant Director of Nursing, or Unit Manager will audit to ensure all weight changes and head-to-toe resident assessments resulted in physician or nurse practitioner notification when warranted.
- Audit results will be forwarded to the QAPI Committee for review and presented by the Director of Nursing.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An LPN administered only one tablet of methotrexate instead of the ordered six-tablet dose for a resident with RA. The facility also failed to maintain ordered midline IV care for another resident receiving IV abx, with observations showing a soiled dressing, site discoloration, and later no midline or IV pump present despite orders for ongoing site monitoring, dressing changes, and line removal after tx completion.
A resident with dementia and COPD had an order for continuous O2 via NC, with SpO2 to be maintained between 88% and 92% and not exceed 92%. The record showed SpO2 readings below 88% on room air and multiple readings above 92% while on supplemental O2, with no nursing interventions documented; the DON stated the resident’s SpO2 should have been better monitored and the physician’s O2 order more closely followed.
A resident with a stage 4 pressure injury and sepsis had ongoing loose stools, but the MAR showed no documented PRN loperamide use and the record showed no provider notification despite repeated large loose stools. The same resident was also receiving daily anticoagulant injections and was observed with dark red urine in an indwelling catheter, yet there was no documented bleeding/bruising monitoring, no progress note about the blood in the urine, and no alert charting.
A resident with chronic GI symptoms, malnutrition, diabetes, depression, and PTSD had persistent watery diarrhea, abdominal pain, and nausea, but the facility did not adequately track stool testing, confirm lab results, or complete the ordered GI referral. The resident reported frequent diarrhea, fatigue, reduced intake, and soreness, while staff documentation showed conflicting entries about specimen refusal versus sleeping, and the lab later had no record of the specimen that was charted as sent. The record also lacked evidence that the GI specialist appointment was scheduled or completed, and a separate resident’s ordered ECHO for pericardial effusion was not documented as scheduled or completed.
A resident with a growing facial lesion had a dermatology consult delayed for about 3 months. The resident’s chart included provider orders for dermatology follow-up, but the appointment remained pending while the lesion increased in size. Notes from the NP and unit manager documented ongoing waiting for the consult, and the DON stated the health plan should have scheduled it and that consults need to be scheduled in a timely manner.
A resident with HTN and HF had an order for metoprolol succinate to be held if the pulse was below 55 bpm, but MAR and pulse record review showed missing pulse documentation on multiple occasions, pulse checks done after the med was given, and doses administered when the pulse was less than 55 bpm. Staff stated the pulse should have been checked before administration, and the DNS confirmed the expectation was to follow the order and hold the med when indicated.
Medication Dose Error and Midline IV Care Failure
Penalty
Summary
The facility failed to administer the correct dosage of Methotrexate Sodium for a resident with rheumatoid arthritis. During medication administration, an LPN poured only one 2.5 mg tablet into the medication cup and then administered the medications, even though the physician order required six tablets by mouth every Wednesday for a total dose of 15 mg. The LPN later stated that she should have given six tablets and not one, and the DON stated that the nurse reported the error to her and was instructed to call the provider and notify the resident. The facility policy stated that medications are to be administered in accordance with prescriber orders. The facility also failed to provide IV device care as ordered for a resident receiving midline therapy and IV antibiotics. Observation showed the resident’s midline dressing dated 5/30/2026 with visible purple discoloration at the insertion site and dry blood under the clear dressing, while an empty antibiotic bag remained in the room. On a later observation, the midline and dressing were no longer present, and the IV pump was also absent. The resident’s orders included weekly dressing changes, every-shift site monitoring, and removal of the midline after treatment was complete. The Medical Director stated that the line is to be removed immediately after the last antibiotic dose, and the DON stated that after a verbal order is obtained it is to be entered into PCC by the end of the shift.
Failure to Follow Oxygen Orders for Resident with COPD
Penalty
Summary
The facility failed to ensure physician orders were followed for Resident #11, who was admitted with multiple diagnoses including dementia and COPD. On 6/8/26, the resident had an order for oxygen via nasal cannula continuously and twice daily for COPD, with oxygen titrated to maintain SpO2 between 88% and 92% and not to exceed 92%. The resident’s medical record showed SpO2 readings below 88% on 5/23/26 at 4:27 PM and 5/16/26 at 10:20 AM while on room air, with no interventions documented. The record also showed multiple SpO2 readings above the ordered range while the resident was on supplemental oxygen, including readings of 95% to 98% on several dates, without any nursing intervention documented. Nursing progress notes likewise documented SpO2 of 97% and 98% on 2 L NC without documented intervention. On 6/9/26, the DON stated the resident’s SpO2 should have been better monitored and the physician’s oxygen order more closely followed by staff and was not.
Failure to Monitor Loose Stools and Bleeding During Anticoagulant Therapy
Penalty
Summary
The facility failed to provide treatment and care according to orders, resident preferences, and goals for Resident 81, who was admitted with a stage 4 pressure injury to the bottom and sepsis and was able to make needs known. For bowel management, the resident reported loose stools for a couple of weeks and later stated they had been having diarrhea with abdominal discomfort for 3 days, so loperamide was started as needed. The bowel monitor documented repeated loose stools over several days, including two loose stools on 06/04/2026, three large loose stools on 06/05/2026, and two large loose stools on 06/06/2026 through 06/08/2026. The resident stated staff had not given any medication for the loose stools, the June 2026 MAR showed no documented doses of loperamide, and the record showed no documentation that the provider was notified of the three large loose stools. Staff interviews indicated that frequent loose stools should have been reported to the provider, PRN medication given, and the resident placed on alert charting, but this did not occur. For anticoagulant therapy, Resident 81 was receiving daily anticoagulant injections starting 05/21/2026. During observation, the resident was lying in bed with an indwelling urinary catheter and dark red urine was noted in the tube and bag; the resident stated, "It's never been like that. It's scary." The EHR showed no monitoring for bleeding and bruising related to anticoagulant therapy, and the progress notes contained no documentation about the blood in the urine or alert charting. Staff interviews confirmed the resident had blood in the catheter for a couple of days and that monitoring for bleeding should have been in place, but it was not.
Failure to Follow Up on GI Symptoms, Stool Testing, Specialty Referral, and Diagnostic Order
Penalty
Summary
The facility failed to assess, monitor, follow up, and implement physician-ordered care for a resident with ongoing gastrointestinal symptoms, and failed to develop a care plan addressing persistent diarrhea. The resident was cognitively intact, had diagnoses including diabetes mellitus, protein-calorie malnutrition, depression, and PTSD, and was documented as continent, independent with toileting and transfers, and using a wheelchair. The resident’s care plan addressed GI issues such as peptic ulcer disease, pancreatitis, and chronic nausea, but it did not include a problem, goals, or interventions for ongoing diarrhea, abdominal pain, stool testing, infectious GI illness, or management of frequent stools. The resident’s provider documented worsening diarrhea, abdominal pain, and nausea, and ordered stool testing for enteric pathogens and C. difficile, along with a GI specialist follow-up. Facility records showed repeated documentation of stool collection attempts, including entries that the resident refused or was sleeping, while the resident stated she never refused and that staff often asked when she could not provide a sample or was asleep. A stool specimen was documented as collected and faxed to the lab as STAT, but the medical record lacked laboratory results for that specimen, and later review with the lab found no record that the specimen had been received. The resident continued to report frequent watery diarrhea, abdominal pain, nausea, fatigue, reduced intake, and soreness from repeated bowel movements and wiping. The record also showed that the ordered GI specialist appointment was not documented as scheduled or completed. Staff interviews identified that the HUC was responsible for scheduling follow-up appointments, while nursing staff were expected to enter orders and follow up on pending testing. The DON stated staff should have followed up on pending stool testing, maintained infection control precautions while awaiting results, and notified the provider if the resident refused specimen collection. The resident was later found to have C. difficile detected on stool testing, and the record showed delayed identification and treatment after weeks of unresolved symptoms. In a separate deficiency, the facility failed to ensure a physician’s order was implemented for another resident with end stage renal disease, pericardial effusion, atrial flutter, chronic heart failure, and dialysis dependence. The physician ordered that an echocardiogram be scheduled for the resident by a specified timeframe, but the electronic record lacked documentation that the ECHO had been scheduled, implemented, or completed. The DON and Administrator stated that physician orders were to be entered and verified, and that medical records staff scheduled appointments and nurse managers oversaw implementation, but the order was not completed.
Delayed Dermatology Appointment for Facial Lesion
Penalty
Summary
The facility failed to ensure a dermatology appointment was scheduled for a resident with a facial skin growth, resulting in a 3-month delay in evaluation. Resident #97 had a raised red growth on the left side of the chin/jaw area, with part of the growth hanging from the chin and tangled with the resident’s long hair. During an interview, the resident stated that the nurse practitioner wanted it removed and that it was benign, and later stated that it was growing and needed to be seen by a dermatologist. Record review showed provider orders dated 2/16/2026 and 3/6/2026 for follow-up with dermatology for the lesion on the left jaw/facial lesion, with the health plan to schedule the appointment. Notes from the nurse practitioner and unit manager documented that the resident had been waiting on dermatology, that the lesion had increased in size over the past month, and that the appointment was still pending. The DON stated the health care plan should have scheduled the dermatology consult and that consults need to be scheduled in a timely manner, and also stated there was no policy for scheduling appointments.
Failure to Follow Hold Parameters for Metoprolol
Penalty
Summary
The facility failed to follow physician orders for a resident admitted with hypertension and heart failure who had an order for metoprolol succinate to be held if the pulse was less than 55 bpm. Review of the MAR and pulse records showed no pulse documentation on multiple dates in May and June 2026, and on several dates the resident’s pulse was taken after the medication had already been administered. The records also showed that metoprolol succinate was administered on several dates when the resident’s pulse was less than 55 bpm. During interviews, staff stated the pulse should have been checked before giving the medication, and the DNS stated the MAR was not triggering for the pulse to be taken prior to administration, while also confirming the expectation was to follow the physician order and hold the medication if the pulse was below 55 bpm.
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