Failure to Provide Water According to Resident Needs and Preferences
Penalty
Summary
A deficiency occurred when a resident, who was admitted with conversion disorder, anarthria, and aphonia, and who had moderate cognitive impairment and was dependent on staff for several activities of daily living, was not provided with water according to their needs and preferences. On the morning of the incident, the resident was observed lying in bed with empty water tumblers and cups. The resident, unable to speak, pointed to the empty tumblers, prompting a licensed vocational nurse to refill them. Staff interviews revealed that night shift nurses were responsible for distributing fresh water at the start of their shift, and morning CNAs were expected to refill pitchers if needed. Further interviews with staff, including the Director of Staff Development and the Director of Nursing, confirmed that water pitchers should be within reach, filled, and checked at least every two hours. The facility's policy emphasized the importance of providing adequate hydration and preventing dehydration. Despite these protocols, the resident's water pitchers were found empty and not refilled as required, resulting in a failure to meet the resident's hydration needs.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 1 was provided with immediate proper hydration on March 27th, 2025, to ensure residents' hydration needs are being met. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents had the potential to be affected by this deficient practice. On March 28, 2025, department supervisors conducted room rounds to follow up with residents and ensure there were no additional concerns related to water hydration. No further issues were identified as a result of these rounds. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 27 to March 28, 2025, licensed nurses and CNAs participated in an in-service training conducted by the Director of Staff Development (DSD)/designee. The training focused on the importance of proper hydration to support residents' overall health and well-being. To reinforce this practice, department supervisors will conduct daily room rounds (Monday through Friday) to ensure water pitchers are filled and within reach of each resident. Any negative findings will be reported to the Director of Nursing (DON) during the daily clinical stand-up meeting for immediate and appropriate follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will provide any negative findings to QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: March 28th, 2025