Failure to Implement Hydration Care Plan for Dependent Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who was at high risk for dehydration. Multiple observations revealed that the resident, who was totally dependent for eating and drinking due to quadriplegia and other significant medical conditions, did not have fluids readily accessible or being offered by staff. The resident was observed on several occasions lying in bed or sitting in a wheelchair without hydration available, and a marked water cup showed no change in water level over time, indicating fluids were not being consumed or offered. Interviews with the resident's family member and staff confirmed that the resident required total assistance and could not independently access fluids. The family member expressed concern that staff were not offering fluids frequently enough, and the RN/Unit Manager acknowledged that the resident was unable to request or obtain fluids on their own. Despite the resident's high risk for dehydration, as documented in the quarterly risk assessment and MDS, there was no care plan focus or physician order in place to address this risk, such as encouraging or offering fluids every two hours. The review of the resident's medical record showed that while there were care plan interventions for assistance with ADLs and monitoring for urinary tract infections, there was no specific intervention or policy addressing the resident's hydration needs. The facility was unable to provide a dehydration policy when requested. These findings demonstrate that the facility did not meet the requirement to develop and implement a comprehensive care plan that addresses all identified needs, specifically the risk for dehydration in this resident.
Plan Of Correction
1) Resident #68's plan of care updated to reflect at risk for dehydration on 8/5/2025 with appropriate interventions. 2) An audit of current residents' quarterly hydration risk evaluation was conducted on 08/20/2025 by Director of Nursing, Nurse Management team, or designee to verify residents to be at risk for dehydration. Care plan reviews with intervention updated to include providing necessary assistance, encouragement and offering of fluids throughout shift, as clinically indicated. 3) An in-service education was conducted on 08/19/2025 by the Administrator, Director of Nursing, or designee with all licensed/registered nurses addressing the significance of hydration risk evaluation completed on admission, quarterly, and/or significant change, and the implementation of a plan of care for a resident at risk for dehydration. 4) The nursing management team, Registered Dietitian, and/or Dietary Manager will review each resident with risk factors for dehydration to ensure appropriate interventions are implemented and an updated plan of care is complete. The Director of Nursing (DON), or designee, will complete five (5) random weekly chart audits for six (6) consecutive weeks to review quarterly hydration risk evaluations and verify that appropriate interventions have been put in place to reduce the risk of dehydration. Audits will assure that care plans remain updated to reflect these interventions. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, frequency of further review and ongoing need for review will be determined by the QAPI committee. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, frequency of further review and ongoing need for review will be determined by the QAPI committee.