Failure to Update Care Plan with Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to update a resident's care plan to include a physician-ordered fluid restriction, despite clear documentation in the medical record and physician orders. The resident had multiple diagnoses, including hypertension, chronic kidney disease, and a history of stroke, and was under a fluid restriction of three liters per day as ordered by the physician. The care plan, however, did not reflect this restriction, and staff were not consistently aware of or monitoring the fluid intake as required. The dietary and nursing departments had specific instructions for fluid provision, but these were not incorporated into the care plan, and intake was not being documented for the resident. Observations revealed that the resident had access to a 600-cc jug of ice water at the bedside, contrary to the fluid restriction order. Interviews with staff indicated a lack of awareness regarding the fluid restriction, and the responsible nurse had not documented the resident's fluid intake. The facility's policy required the interdisciplinary team to develop individualized care plans, but this was not followed in the case of the resident with a fluid restriction.