Failure to Provide Fluids and Follow Weight Loss Protocols
Penalty
Summary
The facility failed to ensure proper hydration and nutrition for two residents, resulting in deficiencies related to both fluid and nutritional management. For one resident with multiple complex medical conditions, including metabolic encephalopathy, type 2 diabetes, acute kidney failure, hypotension, and a stage 4 pressure injury, staff did not provide a water pitcher or fluids at the bedside as required. Multiple observations over two days confirmed the absence of water at the bedside, despite care plan interventions and signage instructing staff to keep the resident hydrated. Interviews with staff, including CNAs, the Director of Staff Development, and the DON, confirmed that there were no fluid restrictions and that water should have been available at all times. Staff acknowledged that the lack of water could lead to dehydration and related complications, and facility policy required water containers to be provided and maintained daily. For another resident with end stage renal disease and dependence on dialysis, the facility did not follow its significant weight loss policy after the resident experienced a weight loss of nearly 7% in one month. The resident's medical record did not show evidence of a change of condition assessment, notification of the physician or registered dietician, a nutritional assessment, or weekly weights as required by facility policy. Interviews with nursing and dietary staff confirmed that these steps were not taken, and the failure was attributed to a lack of communication and awareness among staff. The facility's policy required prompt notification and assessment in cases of significant weight loss, but these procedures were not followed for this resident. Both deficiencies were substantiated through direct observation, record review, and staff interviews. The failures to provide fluids and to follow weight loss protocols were not isolated incidents but were confirmed by multiple staff members and documented in facility policies. The lack of adherence to established care plans and policies placed the residents at risk for dehydration and continued weight loss, as noted in the findings.