Failure to Monitor and Document Fluid Restrictions for Residents with Renal Disease
Penalty
Summary
The facility failed to monitor and accurately document fluid intake for two residents with physician-ordered fluid restrictions, resulting in the residents receiving fluids in excess of their prescribed limits. One resident, with a history of diabetes, renal failure, and dependence on dialysis, had a fluid restriction order of 1200 ml per 24 hours. However, documentation showed that on multiple occasions, the resident was provided with fluids exceeding this limit, with totals ranging from 1312 ml to 1672 ml in a 24-hour period. The provider was not notified when the fluid restriction was exceeded, and documentation was inconsistent or missing in several records, including the medication administration record (MAR), treatment administration record (TAR), and electronic health record (EHR). Staff interviews confirmed that the fluid restriction orders did not clearly specify the amount of fluid to be provided by dietary services, and that documentation of fluid intake was not consistently accurate or complete. Another resident, also dependent on dialysis and diagnosed with end stage renal disease, had a fluid restriction order of 1500 ml per 24 hours, with specific amounts to be provided by dietary and nursing staff. Review of records showed discrepancies between the fluids documented by nursing and those recorded by nursing assistants, with intake amounts documented as high as 1280 ml in a single shift. Additionally, the resident's meal tray ticket did not indicate a fluid restriction, and the dietary supervisor was unaware of the restriction, resulting in the kitchen not being informed of the need to limit fluids. Observations confirmed that the resident had access to multiple cups of fluid at the bedside, and staff interviews revealed a lack of awareness and communication regarding the fluid restriction. The deficiency was further evidenced by the lack of coordination between nursing and dietary departments, incomplete or inaccurate documentation of fluid intake, and failure to notify the provider when fluid restrictions were exceeded. Staff acknowledged that the orders were not followed as written, and that the documentation and communication processes did not meet expectations for ensuring compliance with physician-ordered fluid restrictions.