Failure to Address Poor Food and Fluid Intake Resulting in Resident Dehydration
Penalty
Summary
A resident with multiple diagnoses, including Alzheimer's disease, severe protein-calorie malnutrition, and pressure injuries, was admitted to the facility and assessed as having severely impaired cognitive skills. The resident's care plan included a goal to consume more than 75% of meals to promote wound healing and prevent further skin breakdown. However, meal intake records over several days showed the resident consistently refused meals or consumed only 0–50% of food offered, with several instances of complete refusal. Fluid intake records also indicated the resident was consuming significantly less than the recommended daily amount, with daily totals ranging from 180 ml to 920 ml, well below the dietician's recommendation of 1,830–2,140 ml per day. Despite these ongoing issues, there was no timely intervention or escalation by staff. Certified Nurse Assistants (CNAs) observed and reported the resident's poor intake, but licensed nurses did not notify the Registered Dietician (RD) or the physician as required by facility policy. The RD confirmed she was not informed of the resident's recent poor intake and was unaware of the refusals to eat or drink. The Director of Nursing (DON) also acknowledged that no interventions were documented by licensed nurses to address the resident's poor intake, and the responsible party was not notified until several days after the issue began. Laboratory results revealed the resident was severely dehydrated, with elevated blood urea nitrogen, creatinine, and sodium levels. The facility's policies required prompt reporting and multidisciplinary assessment of poor intake and changes in condition, but these procedures were not followed. The lack of timely notification and intervention resulted in the resident developing dehydration and placed the resident at risk for malnutrition and further health decline.