Failure to Follow Fluid Restriction Order for Resident with CHF
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a fluid restriction order for a resident with congestive heart failure, hypertension, and diabetes was properly followed. The physician's order specified a 2,000 ml fluid restriction in a 24-hour period, with specific allocations for dietary and nursing departments, and required documentation of intake every shift. Medical record review showed that the resident was consistently provided with less than the ordered amount of fluids, being shorted 1,000 ml for 25 days and 700 ml for 44 days. The care plan identified a risk for fluid imbalance and included interventions for assistance and supervision with fluid intake, but these were not effectively implemented. Interviews revealed that the resident frequently expressed thirst and sometimes did not receive fluids when requested. Staff confirmed that the resident regularly asked for water and that requests were reported to nursing, but fluids were only provided if the resident was not over the fluid limit. The registered dietician verified that the resident had been under the fluid restriction amount on all reviewed days. Facility policy required nursing to evaluate and document fluid intake for residents at risk for nutritional problems and to report variations, but this was not adequately done, resulting in the deficiency.