F0684

D

Failure to Recognize and Act on Resident’s Change in Condition Leading to Hospitalization

Douglas, Michigan Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly identify and assess a significant change in condition for a cognitively intact resident with atrial fibrillation, resulting in unmanaged pain, swelling, decreased functional ability, and hospitalization. The resident had a history of unspecified atrial fibrillation and was care planned for potential pain related to AFIB, with interventions to administer analgesics per orders and evaluate pain interventions. However, the care plan did not include any focus, goals, or interventions related to monitoring swelling, daily weights, or use of a cardiac monitor. A Minimum Data Set (MDS) dated 1/23/26 showed the resident was largely independent or required only supervision for bed mobility and transfers, but a subsequent MDS dated 2/13/26, after a hospitalization, showed a decline to requiring maximal assistance for transfers and bed mobility.

Over the period from late January to early February, the resident experienced a 9‑pound weight gain between 12/30/25 and 2/1/26, with an additional 4‑pound gain documented on 2/6/26. A nutrition note on 2/4/26 identified the weight increase and placed the resident on daily weights for seven days, and a weight change note on 2/5/26 documented a significant 7.5% weight gain with no diuretics ordered. The DON later confirmed that the physician was not notified of this weight gain and that the resident was not evaluated by a provider between 2/1/26 and 2/10/26. Review of assessments and progress notes showed no nursing or physician assessments between 1/27/26 and 2/8/26 and no documentation that a provider was contacted regarding the unexplained weight gain during 2/1–2/10/26.

During the first part of February, multiple CNAs observed and reported changes in the resident’s condition, including bilateral leg swelling (left greater than right), increased pain, yelling out with movement, and a need for significantly more physical assistance with transfers and mobility. CNAs reported that the resident, who typically tried to remain independent, now required help lifting her legs into bed and for all transfers, and they noted sock indentations and suspected fluid retention. The resident and a family member reported that for more than a week prior to hospitalization, the resident had unresolved pain and swelling in both lower extremities, decreased mobility, and loss of ability to transfer independently, and that they requested provider evaluation. A practitioner communication form dated 2/2/26 documented a concern about swollen knees, with a provider response on 2/3/26 ordering scheduled acetaminophen and diclofenac gel; a second communication form dated 2/9/26 documented ongoing pain, especially in the lower extremities, and family requests for different pain medications, with a provider response dated 2/17/26 adding an opioid PRN. The PA later stated she was aware of leg pain but not of swelling or the 9‑pound weight gain, and confirmed the resident was not assessed by a provider between 2/1/26 and 2/10/26. On 2/10/26, the resident went to the emergency department with bilateral leg pain and swelling, was found to have bilateral pitting edema and presumed new congestive heart failure with atrial fibrillation with rapid ventricular response, and was hospitalized for three days.

Following the hospitalization, discharge instructions documented diagnoses of acute CHF, AFIB with RVR, and bilateral lower extremity edema, with orders for daily weights and notification of the physician for specified weight gains, and a cardiac monitor placed at discharge. Upon return, the resident required maximal assistance for transfers and bed mobility compared to her prior status. The DON and nursing staff acknowledged that the significant unexplained weight gain, leg swelling, increased pain, and functional decline should have prompted further medical assessment and provider notification, and that the communication method used (written communication sheets placed in a mailbox) was ineffective and contrary to prior education to call providers by phone. The failure to recognize and act on the resident’s change in condition, including not notifying the physician of significant weight gain and progressive symptoms, led to unmanaged pain, swelling, decreased functional ability, and the subsequent hospitalization.