Failure to Provide Fresh Water and Clean Mugs to Residents
Penalty
Summary
The facility failed to provide water consistent with resident needs and preferences, and did not ensure sufficient hydration for residents. One resident with a history of left below the knee amputation, diabetes, and protein calorie malnutrition, who was cognitively intact and independent in mobility, reported that staff did not provide fresh water and that she had to obtain it herself. Observations confirmed that no water mug or cup was present in her room on multiple occasions. She also noted the removal of ice machines, limiting her access to ice water. Two additional residents, both cognitively intact and independent, stated they did not receive fresh water or clean water mugs from staff, instead refilling their own cups from the bathroom sink and reusing the same mug without cleaning. Staff interviews revealed a lack of clarity and consistency regarding the process for providing fresh water and clean mugs to residents. The dietary manager was unaware of any process to ensure daily provision of clean water mugs and fresh water. Nursing staff, including an LPN and a nursing assistant, indicated that water was not routinely passed to residents and that previous methods, such as pitchers of water or ice near the nurses' station, had recently been discontinued without explanation. The assistant director of nursing acknowledged that water pass was not happening consistently, and the director of nursing stated that staff were expected to provide fresh water and clean mugs daily. Facility policy required daily provision of fresh water and clean containers, but observations and interviews indicated this was not being followed.