Failure to Enforce Fluid Restrictions for Dialysis Residents
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents requiring fluid restrictions as part of their treatment for end stage renal disease (ESRD). For one resident with severe cognitive impairment and multiple comorbidities, including ESRD and diabetes, physician orders and care plans specified a daily fluid restriction of 1200 ml. Despite these orders, intake and output records showed that this resident consistently received fluids in excess of the prescribed limit on the majority of days over two consecutive months. Staff interviews confirmed that the resident was given additional fluids upon request, and there was no evidence that staff consistently educated the resident about the fluid restriction or notified the physician of noncompliance, as required by the care plan and facility policy. Additionally, the resident's noncompliance was not addressed in a timely manner by the Interdisciplinary Team (IDT), and the last documented IDT discussion regarding this issue was several months prior to the survey. A second resident, who was cognitively intact and also dependent on dialysis, had a physician-ordered fluid restriction of 1000 ml per day. Intake and output records revealed that this resident also regularly received fluids exceeding the prescribed limit on most days during the review period. Staff interviews and care plan reviews indicated that nursing and dietary staff did not ensure the division and distribution of fluids according to the care plan, and the resident's intake was not adequately monitored or restricted as ordered. There was no documentation of staff providing education about the risks of noncompliance or notifying the physician when the resident exceeded fluid limits, as required by facility policy. Facility policies reviewed during the survey specified that noncompliance with fluid restrictions should be documented, the physician notified, and the IDT convened to address ongoing issues. However, these protocols were not followed for either resident. Observations confirmed that residents had access to fluids beyond their prescribed limits, and staff interviews revealed a lack of consistent communication and intervention regarding fluid restrictions. These failures resulted in the facility not adhering to physician orders and established care plans for residents on dialysis.