Failure to Provide Consistent Access to Hydration for Residents
Penalty
Summary
The facility failed to ensure that six residents consistently had access to water and other beverages in accordance with their needs and preferences, resulting in insufficient hydration. During a group interview, all six residents reported not receiving fresh ice water daily and noted that water was no longer routinely passed to their rooms, despite their desire for daily ice water. Observations confirmed that at least one resident did not have a water pitcher or bottle in her room on multiple occasions, and she was only provided limited beverages with meals. Staff interviews revealed that CNAs were responsible for passing water each shift, but this was not consistently done. The registered dietitian and director of nursing both acknowledged the importance of regular hydration and the expectation that water should be provided every shift, but were unaware that residents were not receiving it as required. One resident, who had diagnoses including severe protein malnutrition, multiple sclerosis, dysphagia, and dementia, required assistance with all activities of daily living and was unable to obtain water independently due to dexterity and mobility limitations. Her records indicated a history of low fluid intake, and her care plan noted the need for assistance with meals and a recommendation for nectar thick liquids, though she had signed a waiver for thin liquids. Despite these needs, there was no documented assessment of her fluid requirements, and observations showed she was not provided with adequate fluids beyond limited beverages at meals.