Failure to Monitor CHF Resident’s Weight Gain and Edema
Summary
The deficiency involves the facility’s failure to monitor and address a resident’s significant weight gain and worsening edema in accordance with physician orders and the resident’s clinical needs. The resident was admitted with diagnoses including atrioventricular block, bradycardia, acute respiratory failure with hypoxia, congestive heart failure (CHF), and atrial flutter. On admission, non-pitting edema was documented in the palms, and the physician ordered Furosemide 20 mg twice daily and weekly weights every Wednesday evening shift. The diuretic care plan also directed staff to weigh the resident weekly and as needed, and the dietary evaluation identified impaired nutrient utilization related to altered sodium and fluid balance secondary to CHF, with instructions to continue monitoring weight trends. Weight documentation and follow-through on ordered and requested weights were inconsistent and incomplete. Early weights included 223 lbs on admission, 221 lbs the next day, and 215.6 lbs on 3/28. A nurse practitioner visit on 4/6 noted weight loss from 223 lbs to 215.6 lbs and specifically requested a repeat weight to confirm the trend and accuracy, but no reweight was documented. Scheduled weekly weights for 4/1, 4/8, and 4/15 were not recorded on the TAR, and the 4/15 weight entry was coded as “09-Other/See Nurse Note” without any corresponding nurse note explaining why the weight was not obtained. The next documented weight did not occur until 4/10, showing 249 lbs, a gain of 33.4 lbs over 13 days, and there was no documentation that this significant weight gain was reported to the provider. Edema assessments showed a progression that was not effectively recognized or acted upon. On 4/6, both the skilled nursing evaluation and the NP’s physical exam documented no edema. Subsequent skilled nursing evaluations on 4/8 and 4/9 did not identify edema, but on 4/10 the resident was documented with +1 pitting edema in both lower extremities, with the onset marked as unknown. On 4/11, 1+ pitting edema persisted bilaterally, again with onset unknown, and by 4/12 the edema had progressed to 2+ pitting bilaterally. On 4/13, 2+ pitting edema was noted in the left lower extremity and 1+ in the right, still documented as unknown if new onset. The NP’s 4/13 visit note did not mention the most recent weight or the significant weight gain. Staff interviews revealed that nurses were not consistently reviewing weights, were unaware of the resident’s CHF diagnosis or the associated monitoring expectations, and did not notify the provider of the 33.4 lb weight gain or the worsening edema. The resident and family later expressed concern about unresolved or worsening tibial edema, and the resident was ultimately sent to the emergency department for loss of consciousness and hypoxia, with the NP documenting concern for worsening CHF and fluid overload in the context of persistent and worsening lower-leg swelling despite diuretic therapy. Interviews with facility leadership and clinical staff further highlighted the gaps in monitoring and communication that led to the deficiency. The DON stated that residents with CHF were to start with daily weights on admission and that nursing was responsible for notifying the physician of a 3 lb gain in one day or 5 lb in one week, but acknowledged that this resident had only an order for weekly weights and that there was a two-week gap in documented weights followed by a large weight increase. The DON also reported receiving an email from the dietitian on 4/14 requesting a reweight, which was not completed within the expected 24 hours and was not found in the record. The NP reported that she expected the reweight requested on 4/6 to be done within a day or two and that she would have expected to be notified of the 33.4 lb weight gain and the change in edema, but she was not informed and was unaware of the weight gain at the time of her 4/13 assessment. These documented failures to obtain ordered and requested weights, to monitor and interpret weight and edema trends, and to notify the provider of significant changes in condition resulted in unrecognized worsening edema, significant weight gain, loss of consciousness, and hospitalization for this resident. The resident’s significant other reported noticing increased leg edema and the resident’s increased difficulty breathing earlier in the week before hospital transfer and believed the edema was not being addressed. Nursing staff interviews showed that day-shift and night-shift nurses divided assessment responsibilities by room number, and at least one RN reported never personally assessing the resident’s edema and not reviewing the resident’s weight. Another LPN believed the resident was admitted with 2+ pitting edema, did not know the resident had CHF because they did not see the diagnosis in the record, and was unaware of any weight changes, despite acknowledging that residents with CHF were supposed to be weighed daily and that providers should be notified of specified weight gains. These combined omissions in assessment, documentation, and provider notification form the basis of the cited deficiency.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with insulin-dependent type 2 DM and mild cognitive impairment had a rapid BG drop after receiving sliding scale insulin. The resident reported fear of overnight hypoglycemia and requested BG checks every 2 hours, but the record did not show overnight monitoring, reassessment, or follow-up. Staff later stated the night nurse was notified, while the resident said BG was not checked again until breakfast.
Failure to provide ordered wound care and aspiration precautions: A resident returned from a dermatology procedure with biopsy-site dressings and the chart lacked documentation of assessment or wound care, while the dressings remained in place and undated during observations. The same resident also had dysphagia with a FEES showing silent penetration with straw sips and an order for no straws, yet was observed drinking water from a cup with a straw; the SLP and DON confirmed the no-straw precaution and expectation to follow physician orders.
Failure to Monitor Ordered Vital Signs: A resident with COPD, chronic respiratory failure with hypoxia, and CHF had a provider order for daily vital signs, but the MAR showed an O2 sat of 87% with no follow-up vitals documented and another day with no vitals documented at all. Nursing notes did not show follow-up monitoring or documentation of the low O2 reading, and the CNO stated vitals were recorded on the night shift but not entered into the record or explained when the day-shift vitals were not completed as ordered.
Medication Administered Despite Hold Parameters: A resident with HTN and hyperlipidemia had an order for midodrine with BP hold parameters, but licensed nurses administered the medication multiple times even when the resident's BP met or exceeded the ordered limits. MAR review showed doses were given despite systolic and/or diastolic readings at or above the hold threshold, and the NHA acknowledged the medication was administered contrary to the physician's parameters.
Failure to assess and report abnormal blood glucose and document change in condition: The facility did not notify the MD of abnormal CBG results or assess for hypo/hyperglycemia for two residents with DM who had insulin orders and abnormal readings, including low and high values. The record also showed inaccurate documentation for another resident with a bruise of unknown origin that was monitored briefly and then no longer documented.
A facility failed to notify the provider about a resident’s weight changes per physician order. The resident had CAD, HF, HTN, and dementia, and the record showed weight fluctuations of 4 lbs and 5 lbs, but there was no evidence the provider was updated. The DON confirmed the provider was never notified and stated the provider should have been informed per the order.
Failure to Monitor Blood Glucose After Rapid Drop
Penalty
Summary
The facility failed to provide the care and services needed to safely manage diabetes for one resident with insulin-dependent type 2 diabetes and mild cognitive impairment. The resident’s care plan directed staff to monitor for signs and symptoms of high and low blood sugar, check blood glucose as ordered, administer scheduled and sliding scale insulin as ordered, encourage bedtime diabetic snacks, and provide ongoing diabetic foot care. On 7/15/26 at 12:25 a.m., the resident had a blood glucose of 330 before dinner and received 4 units of sliding scale insulin as ordered. The resident expressed concern about receiving the full insulin dose because of fear that blood sugar would drop during the night. About one hour later, the resident’s blood glucose decreased to 97. Staff gave 15 grams of carbohydrates and one glass of juice, and the blood glucose increased to 160. The resident then requested blood glucose checks every two hours during the night because of fear that blood sugar would fall below 50, and the nurse documented that the night nurse was notified. However, the medical record did not identify blood glucose monitoring, reassessment, or follow-up during the night. During interviews, the resident stated staff did not check blood sugar until breakfast the next morning and said, "They don't like checking it." Staff and the DON stated residents’ concerns should be documented and reassurance provided when blood sugar concerns were expressed.
Failure to Provide Ordered Wound Care and Aspiration Precautions
Penalty
Summary
The facility failed to provide timely post-procedure wound care for a resident who returned from a dermatology visit after a skin growth evaluation and treatment. The resident came back with dressings covering biopsy sites on the head and face, and the dermatology visit summary instructed staff to allow the pressure dressing to remain in place for 24 hours, then remove it, clean the wound daily with mild soap and water, pat dry, apply white petrolatum, and cover with a Band-Aid until healed. During observations on two consecutive days, the resident was still seen in bed with the dressings on the biopsy sites, and the dressings were not dated. The record contained no documentation that the biopsy sites were assessed upon return from the procedure and no documentation that wound care was performed on either day. The facility also failed to follow physician-ordered aspiration precautions for a resident with dysphagia. A FEES showed silent penetration with straw sips of thin liquids, and the resident was ordered an easy-to-chew diet with no straws. The care plan also directed staff not to provide beverages with a straw. Despite this, the resident was observed drinking water from a cup containing a straw. A CNA stated, "Well how else are we supposed to give him a water cup, we have to provide water." The SLP confirmed the FEES findings and the no-straw precaution, and the Medical Director stated he expected staff to follow physician orders and aspiration precautions for residents with dysphagia.
Failure to Monitor Ordered Vital Signs
Penalty
Summary
The facility failed to monitor vital signs as ordered by the physician for Resident #46, who was admitted with multiple diagnoses including COPD with acute exacerbation, chronic respiratory failure with hypoxia, and congestive heart failure. The facility policy titled Vital Signs stated that vital signs are to be taken as ordered by the provider and documented immediately after measurement, and that abnormal or concerning vital signs must be reported to the licensed nurse for assessment and intervention. A physician order dated 5/19/26 directed that Resident #46's vital signs be taken once daily during the day shift. The June 2026 MAR documented an oxygen saturation of 87% on 6/5/26 with no follow-up vital signs documented, and no vital signs documented on 6/6/26. The resident's nursing progress notes did not document follow-up vital sign monitoring or that the oxygen saturation was below 88%. The CNO stated that there was no documentation of follow-up measures or monitoring related to the low oxygen reading on 6/5/26, and that on 6/6/26 the night shift recorded vitals but did not enter them into the medical record or document why the vitals were not taken during the day shift as ordered.
Medication Administered Despite Hold Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring licensed nurses administered medications according to physician-ordered parameters for one resident. The resident had diagnoses including hypertension and hyperlipidemia. A physician order dated June 24, 2026, directed midodrine 10 mg by mouth three times daily, with instructions to hold the medication if systolic blood pressure was greater than or equal to 120 mmHg or if diastolic blood pressure was greater than or equal to 80 mmHg. Review of the medication administration record and documented blood pressure readings showed staff administered midodrine on multiple occasions even though the resident's blood pressure met or exceeded the ordered hold parameters. The medication was given when blood pressure readings included 125/72, 125/74, 122/80, 112/80, 126/66, 122/68, 126/68, and 126/68. During an interview, the Nursing Home Administrator acknowledged that staff administered the medication despite blood pressure readings that met the physician's ordered parameters requiring the medication to be withheld.
Failure to Assess and Report Abnormal Blood Glucose and Document Resident Change in Condition
Penalty
Summary
The facility failed to notify the physician of increased and decreased capillary blood glucose (CBG) levels and failed to assess residents for hyperglycemia and hypoglycemia, as well as changes in physical assessment, for three residents. Facility policy for hypoglycemia required timely initiation of emergency treatment using approved protocols, and the general documentation policy required accurate, timely documentation of resident status, interventions, and notification of appropriate parties. The facility did not have a specific hyperglycemia policy and relied on physician orders for parameters. Resident R3 had diagnoses including hypertension, diabetes, cerebrovascular accident, and dementia. Physician orders included Lantus 30 units at bedtime and Novolog 6 units with meals, along with sliding scale insulin. The eMAR showed CBG readings of 70 and 67, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified of the abnormal results. Resident R137 had diagnoses including hypertension, diabetes, muscle weakness, and cognitive communication deficit. Orders included checking blood sugars as needed for signs and symptoms of hypo- or hyperglycemia, rechecking blood sugars over 350 in 4 hours, fasting blood sugars every morning, post-prandial blood sugars, and Novolog 25 units with breakfast and lunch plus sliding scale coverage. The eMAR showed blood glucose values of LOW, 432, 45, and 0, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified. Resident R11’s record showed a bruise to the left eye/brow with unknown origin, continued monitoring notes, and then no further documentation about whether the bruise resolved; the Nursing Home Administrator confirmed the facility failed to document accurately for this resident.
Failure to Notify Provider of Significant Weight Changes
Penalty
Summary
The facility failed to update the provider about resident R8’s weight changes per physician order. R8’s record showed diagnoses including coronary artery disease, heart failure, hypertension, and dementia, and the annual MDS indicated R8 was mildly cognitively impaired. A physician order dated 7-9-26 directed daily weights and to report a change of 3 lbs overnight. The weight record showed a 4 lb decrease from 153.5 lbs to 149.5 lbs and a 5 lb increase from 148.5 lbs to 153.5 lbs, but the medical record lacked evidence that the provider was ever notified of these changes. The DON confirmed by email that the provider was never updated, and later stated the provider should have been notified per the order.
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