Failure to Monitor and Document Fluid Intake and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident with end stage renal disease and heart failure received sufficient fluid intake in accordance with physician orders and care plan requirements. The resident was on a 1500 ml fluid restriction, with specific allocations for dietary and nursing shifts, and was to be weighed at the same time daily. However, the clinical record did not include documentation of the total amount of fluids consumed each shift, and there was no physician order to weigh the resident daily as required by the care plan. Observations revealed the resident had access to fluids beyond the prescribed restriction, and meal tickets indicated the provision of fluids not consistent with the restriction. The DON confirmed the lack of documentation and monitoring of fluid intake for this resident. Another resident, who had a history of high blood pressure, dementia, and end stage renal disease, experienced a significant unplanned weight loss of 14.46% in less than one month. The care plan required regular weighing at the same time each day and dietician evaluation for tube feed and flush recommendations. Despite this, the clinical record did not show evidence that the resident was reweighed to confirm the weight loss or that the dietician addressed the significant change. Interviews with facility staff, including the DON and registered dietician, confirmed that the expected protocol for reweighing and dietician consultation was not followed, and the dietician was unaware of the resident's weight loss. These deficiencies were confirmed by facility leadership, who acknowledged the failure to provide care and services necessary to maintain acceptable parameters of nutritional status for both residents. The facility did not ensure proper documentation, monitoring, and response to significant changes in residents' hydration and nutritional status, as required by facility policy and physician orders.