Accolade Healthcare Of Savoy

weight gain before 11/11/25 since R3 had such a significant weight gain we obtained reweights to ensure the weight was accurate. V3 stated physician notification would be documented in a progress note. At 1:50 PM V3 provided a copy of a facsimile (fax) letter dated 11/10/25 notifying V15 of R3's weight gain.

This letter did not document receipt of confirmation or that it was reviewed by V15, confirmed with V3. V3 stated this was the only documentation V3 could locate for R3's weight gain notification. V3 stated V3 also spoke with V15 who said that V15 never received the facsimile notification. At 3:15 PM V3 stated CHF symptom monitoring would be documented on the Medication/Treatment Administration Records and sp02 monitored, if spo2 was abnormal this would prompt for a full respiratory assessment documented in nursing note. V3 confirmed this does not include monitoring for edema. V3 stated the Nurse Practitioners gave the facility a list of things they want to be called about and a list of things to fax, and weight gain is not something they want to be called about. V3 stated the Nurse Practitioners have someone that reviews the faxes, but we don't always receive anything back to confirm they reviewed the information that was sent. On 11/24/25 at 1:00 PM V18 Registered Nurse stated V18 had compared R3's weight on 11/10/25 to the day prior and it was the same, so V18 did not notify the provider. V18 stated V3 DON had staff obtain R3's reweights and V18 was unsure if the provider was aware of R3's weight gain. V18 thought someone had sent a message to V15's office. On 11/24/25 at 1:41 PM V15 stated no one notified V15 of R3's weight gain until 11/11/25, staff should have been following the daily weight CHF protocol and should have notified V15 sooner. V15 stated V15 would have doubled R3's Torsemide dosage for a few days then had Basic Metabolic Panel drawn after the last dose was given. V15 stated on 11/11/25 R3 was lethargic, R3's left arm was swollen and abdomen was distended/stretched, and R3 was not wearing her CPAP. V15 gave orders for a one time dose of Torsemide 40 mg and to reweigh R3 because V15 suspected an error with the weight, but it was confirmed with V17 Assistant at 5:00 PM that R3's weight was accurate. V15 stated R3 was hospitalized for fluid retention and required intravenous diuretics. V15 stated R3's hospitalization could have been prevented if staff had reported R3's weight gain sooner.

The facility's Acute Condition Changes Clinical Protocol dated October 2025 documents prior to notifying the physician of acute changes in condition, the nurse will make observations and gather information to report to the physician, and will utilize the SBAR assessment when appropriate.

This protocol documents for emergencies staff will call or page the physician and request a prompt response and the physician/practitioner will respond in a timely manner to notifications of changes in condition.

This protocol documents many acute changes in condition can be effectively managed at the facility with outcomes comparable to hospitalization.

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