Failure to Monitor and Document Fluid Restriction for Resident with Hyponatremia
Penalty
Summary
The facility failed to monitor and document fluid intake as ordered for a resident with a physician-ordered fluid restriction due to hyponatremia. The resident was admitted with diagnoses including dementia, stroke, and hyponatremia, and had a physician order for a daily fluid restriction of 1.5 liters. Observations showed that the resident was served more fluids than planned at meals, and the resident reported not limiting fluid intake. The tray card and care plan indicated the fluid restriction, but there was no individualized plan for fluid distribution. Record review revealed that no fluid intake was documented in the medical record for the resident over a one-month period. Interviews with staff, including a CNA and an LPN, confirmed that fluids were not being documented, and the DON acknowledged there was no process in place to total or analyze fluid intake for residents on restriction. The facility's policy only required staff to be aware of residents on fluid restrictions, with no further procedures for monitoring or documentation. This lack of monitoring and documentation resulted in the potential for fluid imbalance for the resident.
Plan Of Correction
#1 Resident 6 remains in the facility and does not appear to have been affected by this deficient finding. Documentation of fluid intake has been added to the EMAR for completion each shift. Night shift will complete 24-hr totals and update the provider PRN for concerns. Care plan has been reviewed and updated regarding fluid restriction. #2 All facility residents requiring fluid restriction had the potential to be at risk for the same deficiency. No other residents were found to be affected by this deficient practice. #3 Licensed nurses, CNA's, activity staff, and therapy staff have been educated by the DON or designee regarding residents requiring fluid restriction and necessary documentation. #4 The DON or designee will audit residents requiring fluid restriction for intake documentation 3X a week for 4 weeks, then weekly for 4 weeks. Any identified concerns will be addressed immediately by the DON or designee. Finding will be submitted to the facility QA committee for further recommendations.