SPARKS, NV - A nursing home resident with chronic heart failure experienced untreated fluid retention for days after a physician prescribed medication, according to a recent state inspection that found multiple care planning failures at Hearthstone of Northern Nevada.
Medication Order Lost in System Gaps
During a March 3, 2025 inspection, state surveyors discovered that Resident #83, who has chronic obstructive pulmonary disease, heart failure, and kidney disease, experienced significant swelling in both legs that went untreated despite a doctor's orders for medication.
On February 21, 2025, a healthcare provider documented that the resident complained of significant edema and prescribed furosemide 20 milligrams daily, a diuretic commonly used to reduce fluid buildup. However, when the resident complained again about bilateral leg swelling three days later on February 24, the medication had still not been provided.
"The resident was not being provided medication for edema," the resident told staff, according to the inspection report. Surveyors confirmed the resident had notable swelling in both lower legs during their observation.
Critical Documentation Failures Discovered
The inspection revealed a concerning breakdown in the facility's care coordination system. Despite the physician's documented order for the diuretic medication, no order for furosemide appeared in the resident's official physician orders. Additionally, the facility's clinical records contained no follow-up documentation about the resident's edema condition after the initial provider visit.
When questioned by inspectors, nursing staff were unable to locate any care plan addressing the resident's swelling or the prescribed diuretic medication. The Licensed Practical Nurse on duty explained that care plans were typically entered as needed and reviewed by nursing leadership, but acknowledged no such plan existed for this resident's edema management.
Medical Significance of Fluid Retention Management
Edema, or fluid retention, represents a serious complication for patients with heart failure and requires prompt medical attention. When the heart cannot pump effectively, fluid accumulates in the body's tissues, particularly in the legs and feet. Left untreated, this condition can worsen heart function and lead to dangerous complications including pulmonary edema, where fluid backs up into the lungs.
Diuretic medications like furosemide work by helping the kidneys remove excess fluid and sodium from the body through increased urination. For heart failure patients, timely administration of prescribed diuretics can prevent hospitalizations and potentially life-threatening complications.
The resident's combination of conditions - heart failure, kidney disease, and chronic lung disease - creates a particularly complex medical situation where fluid balance becomes critical. Delays in implementing prescribed treatments can rapidly lead to clinical deterioration in patients with multiple cardiovascular and respiratory conditions.
Industry Standards Require Comprehensive Care Planning
Federal nursing home regulations mandate that facilities develop comprehensive, person-centered care plans for each resident that address all medical conditions and prescribed treatments. These plans must include measurable objectives and specific timeframes for meeting residents' medical and nursing needs.
According to the facility's own policy dated December 2023, comprehensive care plans should be developed to meet residents' "medical, nursing, mental and psychosocial needs." The absence of any care plan addressing the resident's diagnosed edema condition represents a significant failure to meet these regulatory requirements.
Proper care coordination should have included: immediate entry of the physician's medication order into the facility's system, development of a care plan addressing edema monitoring and treatment, regular assessment of the resident's fluid status, and documentation of the resident's response to treatment.
Additional Issues Identified
The inspection also referenced related violations under separate citation tags, suggesting the care planning failures extended beyond this single incident. The facility's Director of Nursing Staff confirmed during the inspection that no comprehensive care plan existed for the resident's edema condition or diuretic medication use.
The systematic nature of these failures - from missing physician orders to absent care plans to inadequate clinical documentation - indicates broader organizational issues with the facility's care coordination processes that could potentially affect other residents with complex medical conditions requiring careful monitoring and treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hearthstone of Northern Nevada from 2025-03-03 including all violations, facility responses, and corrective action plans.
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