Failure to Adhere to Physician-Ordered Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to clarify a physician's order regarding a resident's fluid restriction and did not ensure that staff adhered to the prescribed fluid limits for a resident requiring dialysis. The resident, who had end stage renal disease, was dependent on renal dialysis, and had additional diagnoses including hypertensive heart and chronic kidney disease and dysphagia, was admitted with a physician order for a daily fluid restriction of 1,000 mL. The care plan and dietary instructions reflected this restriction, with specific breakdowns for fluid amounts to be provided by nursing and dietary staff. Despite these orders, documentation in the medication administration record (MAR) and electronic medical record showed that the resident repeatedly received fluids in excess of the prescribed 1,000 mL per day on multiple occasions. Nursing staff and CNAs recorded fluid intakes that exceeded the ordered amount, with some days totaling up to 1,440 mL. There was no documentation of communication with the physician or dialysis physician regarding these overages, nor any indication that the resident or family was noncompliant with the restriction. Interviews with nursing staff, the registered dietician, and the physician confirmed that the fluid restriction was not consistently followed and that the order itself contained unclear or incorrect breakdowns for fluid distribution. Staff acknowledged the discrepancies and the lack of notification to the physician when the resident received excess fluids. The DON and executive director both stated that staff were expected to follow the fluid restriction orders and notify appropriate parties if the orders could not be followed.