Benedictine Health Center: Nurse Skipped MD Alert - MN
The resident, identified in inspection records only as R1, had heart failure, a condition in which worsening leg swelling is a recognized warning sign that something is going wrong. On May 7, 2026, a nurse documented that his edema had increased and applied Tubigrips, elastic compression sleeves, as a new form of treatment. No call was placed to his physician. No note was left in the provider's folder. Nothing in the medical record showed the doctor was told anything had changed.
R1 was later admitted to the hospital. He was still there when inspectors arrived on May 27.
The nurse who made the call, identified as RN-C, said in a phone interview with inspectors that she remembered R1's legs being more swollen and thought the Tubigrips might help since he spent so much time sitting up in his wheelchair. "Let's see how these work the next day or so," she recalled thinking. When inspectors asked her when a nurse should notify a provider about increased edema, she said, "That is a good question." She explained that her usual prompt to call a doctor was a significant change in weight, not swelling alone. She said she didn't remember placing any note or making any call to the physician on May 7.
A nurse practitioner who worked for the same medical service R1 had been under told inspectors that the current standard of care for heart failure includes daily weights and a low-sodium diet, and that a provider should be updated "at the first sign of increased swelling or edema as that was an indication something is not right." The NP had not personally seen R1 and could not speak to the specifics of his care.
The director of nursing told inspectors that all nurses were aware they should check edema daily for a heart failure patient, but that edema was not specifically tracked in the medical record. If a nurse noticed more swelling, the expectation was to review prior charting and compare. The director said notifying the provider could be done by leaving a note in the physician's folder if rounds were coming up soon, though a phone call would be appropriate if the Tubigrips were needed for several days in a row.
The unit manager, RN-B, said she felt immediate notification was reserved for emergencies. She also said any increase in edema should be relayed to a provider, and then added that going from trace edema to 2-3+ edema in a matter of days was, on paper, a significant increase.
Both the director of nursing and RN-B confirmed there was nothing in the medical record showing the provider was contacted on May 7, the day the swelling was identified as worse and the compression sleeves were applied.
The facility had a written policy on changes in condition, updated in November 2025, that required nurses to consult with the attending provider when a resident's physical status changed from baseline or when treatment needed to be significantly altered, and to document that notification in the medical record. The policy listed contacting the provider for changes in physical status and significant treatment changes as a specific procedural step.
But the policy did not define what counted as a significant treatment change. It did not define what the facility meant by acting immediately. Those gaps left individual nurses to decide on their own when a change was serious enough to pick up the phone, and on May 7, RN-C decided it wasn't.
R1 remained hospitalized when the inspection closed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Benedictine Health Center from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 12, 2026 · Our methodology
Benedictine Health Center in DULUTH, MN was cited for violations during a health inspection on May 27, 2026.
On May 7, 2026, a nurse documented that his edema had increased and applied Tubigrips, elastic compression sleeves, as a new form of treatment.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.