Failure to Update Resident Care Plan After Discontinuation of Fluid Restriction Order
Penalty
Summary
The facility failed to maintain accurate medical records for one resident with a history of fluid overload. A Certified Nursing Assistant (CNA) identified that the resident had a green sticker on the door, indicating a fluid restriction was in place. Review of the resident's care plan showed an intervention for fluid restriction of 1500ml per day, which had not been updated. However, upon review of the resident's active orders with the Director of Nursing (DON), it was found that the fluid restriction order had been discontinued several months prior, but the care plan was not updated to reflect this change. The facility's policy requires that clinical records accurately reflect the care provided to ensure continuity of care, which was not followed in this instance.