Failure to Implement Fluid Restriction Order for Dialysis Resident
Penalty
Summary
The facility failed to implement a physician's order for fluid restriction for a resident with end stage renal disease who was dependent on hemodialysis. The physician's order, dated 1/28/2025, specified that the resident should be on fluid restriction and that no water pitcher should be placed at the bedside. Despite this, during an observation on 4/27/2025, a full pitcher of water, a full glass of water, and another half-full glass of water were found on the resident's side table. The resident confirmed awareness of the fluid restriction and stated that water was only consumed with morning medications. Staff interviews confirmed knowledge of the physician's order and acknowledged that the order was not followed, as water was present at the bedside. The Director of Nursing also confirmed that staff are required to implement physician orders for fluid restriction, particularly for residents undergoing hemodialysis. Review of facility policy indicated that fluid restriction orders limiting water at the bedside should be followed as directed by the attending physician.