Failure to Monitor Fluid Intake and Weight Changes for Two Residents
Penalty
Summary
The facility failed to implement its own policies and procedures regarding nutritional management and person-centered care plans for two residents. For one resident with muscle wasting, atrophy, and low sodium levels, there was a physician order for fluid restriction to 1,200 cc per day. Despite this, staff did not monitor or document the resident's fluid intake as required, and a water pitcher was left at the bedside. Multiple staff interviews confirmed that fluid intake was neither tracked nor recorded, and the resident's care plan did not address the fluid restriction. The facility's policy required fluid restrictions to be documented and integrated into the care plan, and water pitchers should not be available at the bedside unless evaluated as appropriate. For another resident with end-stage renal disease and diabetes, a significant weight gain of over 15 pounds was noted. The registered dietitian recommended weekly weights for four weeks, and the physician approved this recommendation. However, there was no order placed for weekly weights, and no weight measurements were recorded for a period of nearly two weeks. The DON acknowledged that the order for weekly weights was overlooked, despite the resident's risk for fluid retention due to dialysis. The facility's own policies required timely implementation and documentation of nutritional recommendations within 72 hours and the development of comprehensive, person-centered care plans within specified timeframes. In both cases, the facility did not follow these policies, resulting in a lack of monitoring and documentation for residents with significant health risks related to fluid and nutritional management.