Failure to Accurately Monitor and Document Fluid Intake for Resident on Fluid Restriction
Penalty
Summary
The facility failed to ensure accurate monitoring and documentation of fluid intake for a resident who was on a physician-ordered fluid restriction. According to the facility's policy, nursing staff are required to document fluid intake for residents with fluid restrictions. However, review of the Intake and Output (I&O) forms for the resident revealed incomplete documentation, with daily totals ranging from 240 ml to 400 ml, and lacking sufficient detail to determine if the prescribed fluid restriction was maintained. Staff interviews revealed that CNAs were aware of the fluid restriction but did not consistently report fluid intake to nurses, and nurses were either unaware of the restriction or only documented fluids they personally provided. The Director of Nursing confirmed that the documentation was inaccurate and incomplete, making it impossible to accurately assess the resident's fluid consumption. The resident involved had diagnoses including Hypertensive Heart and Kidney Disease with Heart Failure, Stage 5 Chronic Kidney Disease, and End-Stage Renal Disease, and was receiving dialysis while in the facility. The physician's order specified a 1000 ml fluid restriction with shift-specific limits, but the lack of accurate documentation and communication among staff meant that the resident's fluid intake could not be properly monitored or controlled as required by the care plan.