Failure to Monitor and Enforce Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to ensure that a physician-ordered fluid restriction was properly monitored and followed for a resident diagnosed with hyponatremia and hypo-osmolality, among other conditions. The resident had a physician's order for a 1500 ml fluid restriction, which was documented in the care plan and dietary assessments. However, there was no clear system in place to track or allocate the total allowed fluids between nursing and dietary services, nor was there documentation of how much fluid was actually provided by each department. Review of the resident's medical record and medication administration record showed that while nursing staff acknowledged the fluid restriction order, they did not record the amount of fluids given during each shift. Dietary staff reported that only the beverages on the meal tray were limited, but other fluid-containing foods such as soups, gelatin, pudding, and ice cream were still provided without being counted toward the restriction. There was no coordination or communication between nursing and dietary regarding the total fluid intake, and the dietitian was unsure of the process or whether nursing was aware of the fluids provided by dietary. Interviews with nursing, dietary, and the dietitian confirmed the lack of tracking and communication regarding the resident's fluid intake. The facility's policy required that fluids be shared between nursing and dietary using a fluid restriction breakdown and that input/output records be maintained for residents on fluid restriction. Despite this, the required monitoring and documentation were not implemented, making it impossible to determine if the resident's fluid restriction was being adhered to as ordered.