Failure to Timely Update Care Plan with Fluid Restriction Orders
Penalty
Summary
The facility failed to ensure the timely review and revision of a resident's person-centered, comprehensive care plan when a physician ordered a fluid restriction. Specifically, a resident with diagnoses including end stage renal disease, hypertensive heart disease, heart failure, and a right femur fracture was placed on a fluid restriction of 960 mL per 24-hour period, with specific allocations for nursing and dietary staff. Despite this order, the resident's care plan did not reflect the fluid restriction or the distribution of fluids among the nursing and dietary disciplines for several weeks after the order was written. Record reviews and staff interviews confirmed that the care plan, dated prior to the fluid restriction order, only addressed risks related to renal failure and fluid imbalances but did not include the new fluid restriction or its breakdown by discipline. The Certified Dietary Manager acknowledged that the care plan lacked this information and was unaware of the policy requiring the dietary supervisor to ensure the care plan included fluid distribution. Nursing staff, including a Licensed Vocational Nurse and the Director of Nursing, also confirmed that the care plan was not updated in a timely manner to reflect the new physician order, and that this omission could result in staff not providing individualized care as required. Facility policies and job descriptions reviewed during the investigation indicated that care plans should be updated within 72 hours of changes in a resident's condition or treatment, and that both nursing and dietary staff are responsible for ensuring care plans are accurate and current. However, the care plan for this resident was not revised to include the fluid restriction and its distribution until several weeks after the order was placed, contrary to facility policy and professional standards.