Failure to Follow Dialysis Residents' Fluid and Medication Orders
Penalty
Summary
The facility failed to adhere to physician-ordered fluid restrictions and medication schedules for two residents requiring dialysis. Resident 37, diagnosed with End Stage Renal Failure and dependent on hemodialysis, was observed with a large cup of water in their room, contrary to the facility's policy on fluid restriction. The resident reported inconsistent refilling of the water cup by staff and a lack of education on fluid consumption limits. The clinical records did not show monitoring of the resident's fluid intake, and the prescribed 1500 ml fluid restriction was not followed. Additionally, the resident's medications, Gabapentin and Calcium Acetate, were not administered as scheduled during dialysis days, resulting in ten missed doses. Resident 56, also diagnosed with end stage renal disease, had a physician's order for a daily fluid restriction of 2 liters. However, the Medical Administration Record did not document the amount of fluid consumed by the resident each shift, indicating a failure to monitor and adhere to the fluid restriction. Interviews with the Nursing Home Administrator confirmed these findings, highlighting the facility's failure to ensure that the physician's orders for fluid restrictions and medication administration were followed for both residents.
Plan Of Correction
1. Facility cannot retroactively document fluid restrictions documentation for resident 37 and resident 56. The times for resident 37's gabapentin and calcium acetate were changed to non dialysis times. 2. Facility completed an audit of residents on fluid restrictions for proper documentation of fluid intake and no other discovered. Current and new admit dialysis residents could be at risk for proper documentation of fluid restrictions and medication administration while at dialysis. 3. DON, or designee, will educate nursing staff on policy "encouraging and restricting Fluids." 4. DON, or designee, will perform random audits of fluid restrictions in cc's weekly for 2 weeks, then monthly for 2 months. DON, or designee, will perform random audits to ensure dialysis residents do not have orders to administer medications while at dialysis. Results of audits will be submitted to monthly QAPI for review and recommendations.