F0580

D

Failure to Notify Physician of Resident’s Significant Weight Gain, Edema, and Functional Decline

Douglas, Michigan Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify the physician of a significant change in condition for one cognitively intact resident with atrial fibrillation, who experienced a rapid, unexplained weight gain, progressive lower extremity swelling, increased pain, and loss of functional abilities. The resident gained 9 pounds over 32 days, with an additional 4-pound gain documented shortly thereafter, and a weight change note identified a +7.5% significant weight gain with daily weights ordered for monitoring. Despite this documented significant weight gain and the absence of diuretics, there was no evidence that a provider was notified, and no nursing or physician assessments were completed between late January and early February.

Over the course of more than a week, the resident reported unresolved pain, swelling in both lower extremities, and a loss of ability to transfer independently, ultimately insisting on going to the emergency room. The resident stated her pain reached 8/10 and that she repeatedly asked to be seen by a physician but was not evaluated. Family reported they requested a provider evaluation and were told the resident would be seen, but this did not occur; they also observed the resident crying from pain. CNAs reported that between early and mid-February the resident’s legs were swollen and painful, socks left indentations, the resident yelled out during care, grabbed her legs, and required increased assistance with transfers and mobility, and they stated they reported these changes and concerns, including suspected fluid retention, to nursing staff.

Nursing documentation and interviews showed that although staff were aware of the resident’s new and worsening symptoms, including leg swelling, increased pain, and decreased mobility, the physician was not notified of the significant weight gain and associated changes. Practitioner Communication forms reflected concerns about swollen knees and pain, with provider responses limited to adding scheduled acetaminophen, topical diclofenac gel, and later a PRN opioid, but there was no indication the provider was informed of the 9‑pound weight gain, bilateral lower extremity swelling, or functional decline. The PA confirmed she was unaware of the resident’s weight gain and leg swelling, that the resident was not assessed by a provider during the relevant period, and that communication sheets placed in provider mailboxes were often overlooked, despite providers being available by telephone 24/7. This sequence of events resulted in the physician not evaluating the resident when she experienced a significant change in condition and was subsequently hospitalized.