Failure to Implement Fluid Restriction Care Plan for Resident with ESRD
Penalty
Summary
The facility failed to implement a care plan related to fluid restriction for a resident with End Stage Renal Disease (ESRD) who was on hemodialysis. The resident's care plan specified a 1000 ml fluid restriction per day, with specific limits for each shift, and required documentation of fluid intake. However, review of the resident's Intake and Output (I&O) forms over a specified period revealed incomplete documentation, with daily totals ranging from 240 ml to 400 ml and lacking sufficient information to determine if the prescribed fluid restriction was maintained. Interviews with the Director of Nursing (DON) and the Minimum Data Set (MDS) Nurse confirmed that staff were not consistently following the care plan regarding fluid restriction and intake documentation. The MDS Nurse stated that failure to document total daily fluid intake meant the care plan was not being implemented, which could result in the resident receiving more fluids than ordered. The resident had diagnoses including Hypertensive Heart and Kidney Disease with Heart Failure and Stage 5 Chronic Kidney Disease.