Failure to Monitor Fluid Restrictions and Notify Provider of Medication Refusals and Weight Changes
Penalty
Summary
The facility failed to properly monitor and document fluid restrictions for two residents with significant medical conditions requiring such interventions. One resident with anemia and end stage renal disease on hemodialysis had a care plan and provider order for a 1200 ml fluid restriction, but records showed an intake of 1580 ml on one day and multiple shifts where fluid intake was either not documented or marked as 'NA' or 'X' instead of recording the actual amount. Another resident with anemia, heart failure, and renal insufficiency had a care plan and orders for a 1920 ml daily fluid restriction, but over several months, numerous shifts lacked any documentation of intake or used 'NA' instead of actual numbers. Interviews with nursing staff confirmed the lack of consistent documentation and the importance of tracking fluid intake for residents with such restrictions. Additionally, the facility did not notify the provider when a resident with multiple chronic conditions, including atrial fibrillation, morbid obesity, chronic kidney disease, hypertension, and COPD, refused prescribed diuretic medication and experienced significant weight gain. The resident's orders required notification of the heart center for weight changes of five pounds or more in a week and documentation of refusals. However, the electronic medical record did not reflect provider notification for either the medication refusals or the weight gain, despite the resident refusing the diuretic for several days and gaining over 14 pounds in a short period. Interviews revealed that some notifications may have been made outside the EMR, but there was no consistent documentation as required by policy. The facility's own policy on refusal of treatment required detailed documentation of refusals, including the resident's response, reason for refusal, and provider notification, but this was not consistently followed. The director of nursing and nurse manager both stated expectations for documentation and provider notification in such cases, but the records did not support that these actions were taken according to policy.