Failure to Provide Accessible Water at Bedside
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease and renal insufficiency, who was severely cognitively impaired, did not have water available at the bedside as required. Multiple observations over two days showed that the resident's water cup was consistently placed on the sink counter, approximately eight feet away from the bed, and not within the resident's reach. The resident was observed lying in bed with dry lips and reported feeling thirsty. No other beverages were present in the room during these observations. Interviews with staff confirmed that the expectation was for water to be kept within reach of residents and replenished at least every shift. Staff also acknowledged that the resident had difficulty holding the standard maroon cup and should have been provided with a more suitable cup. The facility's policy required fresh water to be available to residents at all times, but this was not followed for the resident in question, as evidenced by the repeated lack of accessible water and low recorded fluid intake.
Plan Of Correction
Corrective action took place immediately upon identification of the issue by moving the water within the resident's reach. All residents have the potential to be affected. Education to all staff related to ensuring water is within patient reach at all times in the resident's room. Policies were updated to reflect that water must be within the resident's reach in their room: Water Pass policy, TEMP Purposeful Rounding policy. Five weekly audits of water location within resident's reach in their room will be completed for the next 12 weeks. The Executive Director is responsible for compliance.