Failure to Implement Care Plan for Intake and Output Monitoring
Penalty
Summary
The facility failed to implement the care plan for a resident with chronic kidney disease, heart failure, and dementia. The care plan, initiated due to impaired renal function, required monitoring of the resident's intake and output to prevent renal complications. Despite this intervention being documented in the care plan, there was no evidence that intake and output were actually monitored or recorded for the resident. Both a licensed vocational nurse and a registered nurse supervisor confirmed the absence of documentation regarding intake and output monitoring during interviews and record reviews. The resident in question was totally dependent on activities of daily living, had severe cognitive impairment, was incontinent of urine and bowel, and received nutrition via a gastrostomy tube. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables to be developed and implemented for each resident. However, the lack of documentation and monitoring of intake and output as specified in the care plan constituted a failure to meet the resident's hydration and nutritional needs as outlined in the plan.