Failure to Develop Dehydration Care Plan for At-Risk Resident
Penalty
Summary
The facility failed to develop a care plan addressing dehydration for a resident with a known risk and history of dehydration. Medical record review showed that the resident, who had dementia, dysphagia, severe cognitive impairment, and was dependent on staff for feeding, was admitted with physician orders for a puree diet and thickened liquids. Following a hospitalization for dehydration, discharge orders specified a required daily water intake. Despite these risk factors and medical directives, the resident's comprehensive care plan did not include any goals or interventions for dehydration prevention. This omission was confirmed during a staff interview, which verified the absence of measurable goals and interventions related to dehydration in the care plan.