Failure to Monitor and Implement Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to monitor and implement a physician-ordered fluid restriction for a resident with multiple comorbidities, including hypertension, chronic kidney disease, angina, and a history of stroke. The physician's order specified a daily fluid restriction of three liters, with detailed instructions for the distribution of fluids by shift and department. However, the resident's care plan did not include the fluid restriction, and staff were not consistently aware of or following the order. Observations revealed that the resident had access to a 600-cc jug of ice water at the bedside, contrary to the restriction, and staff interviews confirmed a lack of awareness and documentation regarding the fluid restriction and intake monitoring. Further review of facility policy indicated that staff were expected to follow specific instructions for fluid restrictions, including removing water pitchers from the room and recording intake. Despite these guidelines, nursing staff had not documented the resident's fluid intake, and the care plan lacked the necessary information about the restriction. The failure to implement and monitor the fluid restriction as ordered placed the resident at risk for complications related to hydration status, particularly given the resident's cardiac and renal conditions.