Failure to Adhere to Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to ensure that a resident with a physician-ordered fluid restriction received the correct amount of fluids as prescribed. The resident, who had diagnoses including heart failure, coronary artery disease, peripheral vascular disease, and renal insufficiency, was cognitively intact and functionally independent. According to the physician's order, the resident was to receive a total of 1200 cc of fluids per 24 hours, with specific amounts allocated for each meal. However, observations revealed that the resident's meal trays contained more fluids than allowed, such as 480 cc at lunch and 600 cc at breakfast, exceeding the prescribed limits. Interviews with both the resident and facility staff confirmed that the fluid restriction was not consistently honored. The resident reported that meal trays sometimes included too many fluids, and both the dietary cook and a registered nurse acknowledged that the resident occasionally received more fluids than ordered. The dietary cook specifically admitted to placing 600 cc of fluids on a breakfast tray when only 360 cc should have been provided, demonstrating a failure to follow the fluid restriction order.
Plan Of Correction
F692 The facility failed to follow resident #198's fluid restriction as ordered and failed to document/care plan resident refusal/non-compliance. Step 1: The facility ADON immediately removed additional ice water at bedside and updated resident's fluid restriction order to include documentation if resident is non-compliant, and care plan updated for resident #198. Completed on 6/9/25. Step 2: To identify other residents that have the potential to be affected, DON or designee reviewed all residents with fluid restriction orders as well as their corresponding care plans for accuracy. Completed on 6/9/25. Step 3: To prevent this from recurring, the DON or designee will educate staff on fluid restrictions including orders, non-compliance, fluid breakdowns, and need for proper documentation. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will audit fluid restriction orders, care plans, and documentation weekly x4 weeks then monthly x2 months. Audits will begin 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.