Failure to Monitor and Record Fluid Intake for Resident on Fluid Restriction
Penalty
Summary
The facility failed to accurately monitor and record the fluid intake for a resident with a physician-ordered fluid restriction of 1200 ml per 24 hours, divided between nursing and dietary staff. The resident, who had diagnoses including stage 4 chronic kidney disease, type 2 diabetes, and acute systolic heart failure, was observed consuming coffee in addition to milk during lunch. The certified nursing assistant (CNA) who provided the coffee acknowledged knowing about the fluid restriction but did not verify with a nurse before giving the additional fluid. Further interviews revealed that the actual fluid intake for the resident was not being recorded by nursing staff, and there was no documentation of fluid intake for each shift in the resident's medical record. The facility's policies required accurate recording and division of fluids for residents on restriction, but these procedures were not followed, resulting in a failure to implement the physician's order for fluid restriction.