Failure to Monitor and Maintain Adequate Hydration for a Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident received adequate fluid intake to maintain acceptable hydration. The resident, who had multiple diagnoses including multiple sclerosis, chronic kidney disease, weakness, and dysphagia, was consistently not meeting the recommended daily fluid intake of greater than 1,400 ml. Despite the facility collecting intake data, staff did not total or assess daily fluid intake, and there was no ongoing assessment for signs and symptoms of dehydration. The resident experienced significant weight loss and was hospitalized twice within a short period for conditions related to dehydration and aspiration pneumonia, both times requiring intravenous fluids. The facility's own policies required assessment and care planning for dehydration risk, including monitoring fluid intake, weighing residents weekly, and updating care plans as needed. However, the facility failed to weigh the resident upon readmission after hospitalization, did not weigh the resident weekly as ordered, and did not update or revise care plan interventions to address the ongoing risk of dehydration and weight loss. There was also a failure to timely communicate significant weight changes to the provider. Interviews with staff revealed confusion about who was responsible for totaling daily fluid intakes, and it was confirmed that no one was consistently performing this task. Documentation showed that the resident's fluid intake was regularly below the recommended amount, and there was no evidence of dehydration assessments being performed. The resident's care plan included approaches to encourage fluid intake and monitor for signs of fluid imbalance, but these interventions were not effectively implemented or updated in response to the resident's declining condition. The lack of daily monitoring and assessment contributed to the resident's repeated hospitalizations and significant weight loss.