How did this Happen? Root Cause Analysis of a Thirty-five Pound Weight Gain in a Skilled Nursing Facility

Introduction/Objective: Congestive heart failure (CHF) is a common syndrome among skilled nursing facilities (SNF) patients. Exacerbations of CHF leading to hospital admissions are common. We use the case of a 35 pound weight gain in a SNF patient with CHF to illustrate risk factors for CHF exacerbations despite the presence of skilled nursing. The goal of this poster is to highlight the need for standardized care of SNF patients with heart failure such as the DEFEAT protocol.