Failure to Monitor Hydration Status Post-Hospitalization
Penalty
Summary
The facility failed to provide adequate care and services for a resident following hospitalization, as evidenced by the lack of interventions related to hydration status in the resident's care plan. The resident, who had a history of dementia, Wernicke's encephalopathy, and schizophrenia, was admitted to the facility with a care plan that did not address hydration needs. After being hospitalized for acute metabolic encephalopathy and hypernatremia, conditions often linked to dehydration, the resident's discharge paperwork emphasized the need for increased oral fluid intake. However, the facility did not update the resident's care plan or Kardex to include instructions for monitoring hydration status. The clinical records and physician's orders post-hospitalization did not contain any notes or directives regarding the resident's fluid status, despite the hospital's recommendations. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the oversight, acknowledging that the facility did not provide the necessary care and services for the resident after their hospitalization. This deficiency highlights a failure to adhere to professional standards of practice and the comprehensive person-centered care plan required for the resident's well-being.
Plan Of Correction
1. Resident R27 is currently being fed by staff for all meals. Hospice and physician will be notified if R27 has a decrease in fluid intake, for new orders. 2. The last 14 days of all re-admissions and new admission discharge paperwork will be reviewed by the DON or designee to ensure instructions for fluid recommendations are followed. 3. Licensed staff will be in serviced on reviewing all re-admissions and new admission's discharge records to ensure fluid recommendations are reviewed and implemented. 4. The Director of Nursing or designee will review discharge paperwork for all re-admissions and new admissions to ensure fluid recommendations have been reviewed and implemented weekly x4 weeks. The QAPI committee will determine the need for further audits.